Insurance Provided by

Member Companies of

American International Group, Inc.

AIRCRAFT OPERATORS: PLEASE COMPLETE SEPARATE AIRCRAFT INSURANCE APPLICATION.

Applicant’s Name:

Mailing Address:

Name of Airport:

Applicant is: Individual Partnership Joint Venture Corporation Other:

Type of Business is: FBO FAA Certified Repair Station Other:

Number of years in business: Under this management: At this location:

Number of employees:

PREMISES

List all buildings, hangars, ramps and all other premises to be insured:

Applicant occupies: All of Premises Part of Premises

Applicant is: Owner Tenant General Lessee of Premises

Who is responsible for maintenance of these premises?

Applicant Does Does Not have air shows, contests, or exhibitions on premises.

List all autos and mobile equipment such as aircraft tugs or fuel trucks used solely on the airport premises.

Runways are: Paved Unpaved

Shortest runway is feet. Approach obstructions? YES NO If YES, explain:

PRODUCTS & COMPLETED OPERATIONS (Products & Services)
Total Gross Receipts: $ for last 12 months $ estimated next 12 months.
Describe products and services:
Types of aircraft worked on:
Applicant is a dealer or distributor for:
Professional Training Courses attended by your employees:
ESTIMATED GROSS RECEIPTS NEXT 12 MONTHS FOR REPAIR OF:
Airframe & components: $ Total % Fixed Wing % Rotorwing

Engines & components: $ Total % Fixed Wing % Rotorwing

% Major Overhauls

% “Hot Section” repairs

Avionics: $

Propellers: $

Rotorsystems: $
ESTIMATED GROSS RECEIPTS NEXT 12 MONTHS FOR:
Airframe painting: $

Sale of parts, not installed: NEW: $ USED: $

Sale of fuel and oil (excluding Pumping Fees): $ Pumping Fees: $

Does Applicant fuel/defuel any airlines? YES NO If YES, describe:

Sale of aircraft: NEW: $ USED: $

Sale of food / beverages (including vending machines): $

Sale of other items and services: $ Describe:

Airline servicing (other than fuel): $ Describe:

Has Applicant performed any engine or airframe modification work? YES NO If YES, describe:

Has Applicant ever sold, serviced or repaired ultra-light or home-built aircraft? YES NO If YES, describe:

HANGARKEEPER’S LIABILITY (Aircraft in Applicant’s Care, Custody or Control)

Average value any one aircraft:	$	Average Total all aircraft:	$	Average number:
Maximum value any one aircraft:	$	Maximum Total all aircraft:	$	Average number:
Maximum value in any one hangar:	$	Describe hangars:
Tied down:	$	Number of tie downs:
Gross Receipts for Next 12 Months Hangar Rental:	$
Tie downs:	$
Towing:	$

Does Applicant fly customer’s aircraft? YES NO List all purposes of use:

Largest type aircraft flown: Maximum value: $

Does Applicant maintain separate Non-Owned Aircraft Liability insurance? YES NO

CONSTRUCTION, DEMOLITION & ALTERATIONS

Projected contract costs for next 12 months:

By Applicant: $ Describe:

By independent contractors: $ Describe:

CONTRACTUAL LIABILITY (“Hold Harmless” agreements/indemnification clauses)

Does Applicant assume liability of others? YES NO Attach all contracts assuming liabilities of others. All attached.

CLAIMS HISTORY & FAR VIOLATIONS – List all Claims and Far Violations for Past 10 Years

Date	Amount (including all expenses)	Cause / Violation
$
$
$
$
$
$
$
$
$
$
Attach separate sheet if needed to fully complete.

COVERAGES & LIMITS REQUESTED

Policy period: From until both at 12:01 a.m. at the Applicant’s address on the front page.

COVERAGES	LIMITS OF INSURANCE
Commercial General Liability Coverage

General Aggregate Limit (other than Products/Completed Operations)

$
Products/Completed Operations Aggregate Limit	$
Personal and Advertising Injury Aggregate Limit	$
Each Occurrence Limit	$
Fire Damage Limit (any one fire)	$
Medical Expense Limit (any one person)	$
Hangarkeeper’s Liability Coverage

Each Aircraft Limit

Each Loss Limit

Deductible (each aircraft)

$

$

$
TOTAL ADVANCE PREMIUM	$

POLICY DEDUCTIBLE

Each occurrence $ Annual Aggregate: $

Other coverages, restrictions, endorsements:

CURRENT INSURANCE

Name of Insurance Company: Expiration Date:

Coverages:

Limits: Deductible: $ Premium: $

NOTICE TO APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or, conceals, for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent act, which is a crime, and subjects such person to criminal and civil penalties.

NOTICE TO NEW YORK APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

NOTICE TO KENTUCKY APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime.

NOTICE TO PENNSYLVANIA APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

NOTICE TO NEW JERSEY APPLICANTS: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.

NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony in the third degree.

NOTICE TO COLORADO APPLICANTS: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Authorities.

NOTICE TO ARKANSAS AND NEW MEXICO APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit, or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

NOTICE TO UTAH APPLICANTS: Any person who knowingly presents false or fraudulent underwriting information, files or causes to be filed a false or fraudulent claim for disability compensation or medical benefits, or submits a false or fraudulent report or billing for health care fees or other professional services is guilty of a crime and may be subject to fines and confinement in prison.

NOTICE TO MAINE APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.

NOTICE TO TENNESSEE AND VIRGINIA APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.

NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.

NOTICE TO LOUISIANA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit, or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

NOTICE TO OKLAHOMA APPLICANTS: WARNING: Any person who knowingly and with intent to injure, defraud, or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony (365: 15-1-10, 36 S.S. 3613.1)

ALL INFORMATION HEREIN IS WARRANTED TO BE TRUE TO THE BEST OF MY KNOWLEDGE AND NO INFORMATION HAS BEEN SUPPRESSED OR WITHHELD, AND NO INSURER HAS CANCELLED OR REFUSED TO RENEW THIS INSURANCE. I UNDERSTAND THAT THE INFORMATION HEREIN AND THE TRUTHFULNESS THEREOF WILL BE THE BASIS OF ANY INSURANCE PROVIDED BY THE COMPANY. THIS APPLICATION DOES NOT BIND THE APPLICANT OR THE COMPANY TO PROVIDE ANY INSURANCE.

Applicant Signature	Today’s Date

To Be Completed By Producer

Producer:

Address: City: State: Zip:

Telephone Number: Fax Number:

APP-04 (02.2005)

AVIATION GENERAL LIABILITY INSURANCE APPLICATION

American International Group

2007-07-27

AIG