| Present
Insurance Company
(not agent) |
|
| Policy
Expirattion Date |
|
Please
enter date as: mm/dd/yyyy
Example using today's date: 02/09/2012
|
| Name
of Airport |
|
| City
and State |
|
| Please
provide a brief descripton of
your operations |
|
| |
| Airport
Coverage |
|
Airport General Liability Limits:
|
|
| |
$500,000 Combined Single Limit |
|
$1,000,000 Combined Single Limit |
|
$2,000,000 Combined Single Limit |
| (Please Check the following if required.) |
| |
Products |
Products/Completed Operations |
| |
| Medical Coverage
$1,000
$2,500
$5,000 each person |
| |
|
Hangarkeepers
Liability Limits |
$50,000 each aircraft, $100,000 each occurence |
|
$100,000 each aircraft, $300,000 each occurence |
|
$250,000 each aircraft, $500,000 each occurence |
|
$
each aircraft, $
each occurence |
| |
| Fixed
Base Operations
General Information |
|
Do you occupy: |
|
| |
Office Square feet
|
|
Hangar(s) Square ft. 1st Hangar
2nd
3rd
|
| Total
number of Tie-downs on your premises:
|
| Average
value of aircraft tied out $
|
|
Number of aircraft hangered
|
Average
value of aircraft hangered $
|
| |
Is
Applicant the Airport Manager?
yes
no |
| Any
other locations at other airports occupied by applicant?
|
| Are
Ultralight, Parachuting or Agriculture operations
conducted on the premises?
yes
no |
| Number
of vehicles owned/used by applicant: Fuel trucks
Tugs
|
| Has
appicant had any airport-related losses/claims during
last 4 years?
yes
no |
|
If yes explain: |
|
| |
| Operations
Information |
|
Types
of
services proviced
by applicant
and gross
receipts for
each operation |
Fueling $
|
Maintenance $
|
|
Parts Sales $
|
Avionics $
|
|
Aircraft Sales $
|
Other
$
|
| |
| Fueling |
|
Types of fuel sold: |
|
|
Jet
Fuel
Gallons Avgas
Gallons Auto Fuel
Gallons |
|
Type of fuel storage: |
|
|
Underground Tank
Above ground Tank
Fuel Truck |
|
Fuel is dispensed from: |
|
|
Fuel truck
Fuel Island
Fuel Island-Self -Service |
| |
|
Maintenance |
|
Type of Aircraft Maintained: |
|
|
Single Engine
Multi-Engine
Rotorcraft
Turbine |
|
Do you Overhaul or Manufacture
: |
|
|
Engines
Propellers
Kit Planes
Accessories |
|
|
Inventory, Rotables, Spares
|
| Value of Inventory |
|
| Value of Goods of others in Care, Custody & Control |
|
| Revenues last 12 months |
|
| Revenues projected next 12 months |
|
| Provide brief description:
|
|
|
|
|
|
|
|
|
|
