Fixed Base Operators - Aviation Insurance - Emery Little Insurance Brokers in Wiltshire

Aviation Premises, Hangarkeepers and Products Liability Insurance Proposal

Name of Insured

Address of Insured

Telephone Number

Facsimile Number

Telex

Contact Name

Premises

1) Does applicant own or occupy any airport premises?
If yes, please list airport name(s)

2) List all buildings, hangars, ramps and all other premises to be insured.

3) Applicant occupies: All / part of premises and is Owner / Tenant / General lessee of premises

4) List all vehicles and mobile equipment, such as aircraft tugs and fuel trucks, used on the airport premises.

5) Describe your main activities.

6) Anticipated revenue from this source of business.

Hangarkeepers

7) Does applicant ever have non-owned aircraft in his care, custody or control at his premises?
If yes, please provide the following details.

a) Average value any one aircraft

b) Average total value at any time

c) Maximum value any one aircraft

d) Maximum value at any time

e) Maximum value in any one hangar

f) Maximum value outside hangars

g) Average number of aircraft in your care, custody or control

h) Please provide details of any rotor wing aircraft included in above

i) Average number of engines in your care, custody or control

8) Do you require in-flight hangarkeepers coverage?

9) Anticipated revenue from this source of business

Products Liability

(Appropriate for Non Manufacturing Exposures and / or Ariel Form Section 3 - small to medium companies)

10) Name of any Subsidiaries with Aviation Products

11) Sales (US$)

Civil

Military

Past 12 months

Fixed Wing

Rotor Wing

Total

% split between:

Airframe and

Engines / Propellers / Rotors

Sales of Fuel (if any) and approximate gallonage per annum.

Estimates for next 12 months

Fixed Wing

Rotor Wing

Total

% split between:

Airframe and

Engines / Propellers / Rotors

Sales of Fuel (if any) and approximate gallonage per annum.

12) How long has Insured been in the aviation business?

13) Description of Insured's aviation activities (e.g. repair station, paint spray shop, refueller, avionics specialist, engine or propeller shop)

14) What types of aircraft does Insured usually work on?

15) Does the Insured manufacture any aviation products? Please specify.

16) Does the Insured represent any manufacturers of products? Please specify.

17) Has the Insured signed any aviation contracts that include additional Insured, hold harmless, waiver of subrogation or indemnity provisions that may affect this insurance?

As far as known has the Insured exposed itself, or, protected itself when signing contracts affecting this insurance?

18) Does the Insured do any business with customers or agents domiciled in the USA?

19) Describe the experience and general training levels of Insured's aviation personnel.

20) Have any claims been made against the Insured during the past 10 years? If so, what were the details and amounts involved?

21) If previously uninsured, give details of any payments made to claimants.

22) Does the Insured currently buy aviation products liability coverage? If so, with whom?

23) All aviation products liability policies contain an aggregate limit of liability. What limit of liability do you require?

24) Please provide any other information which you feel may be relevant to this proposal.

Summary of Products Liability coverage provided

Bodily Injury or property damage arising out of the possession, use, consumption or handling of any goods or products manufactured, constructed, altered, repaired, serviced, treated, sold, supplied or distributed by the Insured or his employees after such Aviation goods or Aviation products have ceased to be in the possession or under the control of the Insured.

The Products section of this questionnaire is not intended for operations involved in aircraft catering, aircraft refuelling or jet airliners.

Declaration

By submitting this form I hereby declare that to the best of my knowledge and belief, the particulars and answers herein are true and correct and that I have not knowingly withheld any information which would influence the decision of the underwriters in regard to this proposal.

It is understood and agreed that this proposal shall form the basis of the contract should this policy be issued.

Tel 0870 770 9170

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