Turbine Powered Aircraft

Insurance Application
2580 Foxfield Road Suite 203 | Saint Charles, IL 60174 | (630) 584-7552 | fax (630) 584-2099

Renew al of Policy Number:

Policy Effective:
Client Service Manager:
Broker:

Name of Applicant:
Address:
Primary Contact: Phone Number:
Present Aircraft Insurance Company:
Aircraft Schedule
No of Seats Medical
Aircraft Insured Aircraft Liability
Year Make & Model Reg. No. Payments
Pax Crew Value Each Occurrence
Each Pax

Aircraft Usage
Average Estimated Annual
Aircraft
Passenger Load Flight Hours
FAA No.
Total Employees Guests Part 91 Part 135 Other*

*Describe “Other” Flight Hours:

Aircraft Ownership
Applicant is: [ ] Individual [ ] Corporation [ ] LLC [ ] Partnership [ ] Other:

Name and address of aircraft ow ner, operator and/or lessor (if

other than applicant):
If an LLC, is the holding company have any other business other
than the ow nership of the aircraft?
Will the aircraft be managed by another party (not applicant)? [ ] Yes [ ] No

Name of Charter or Management Company: Years In Business:

Air Taxi Certificate Number: Home Base:

Additional Interested Parties (LH = Lienholder, AI = Additional Insured, LP = Loss Payee; OT = Other)
Name and Address Interest

Are engines, spare engines, or other aircraft equipment subject

[ ] Yes [ ] No
to separate lien or ow nership? (If “Yes” describe)

Page 1 of 4
NA-TAC 11/09 DJWAIRL-01
 Aircraft Operations – Explain All “yes” answers
Will any charge be made for the use of the aircraft? [ ] Yes [ ] No
Will the aircraft be used for any purpose other than transporting
people? [ ] Yes [ ] No
Will the aircraft be used anyplace other than at paved runw ay
[ ] Yes [ ] No
airports?
Will the aircraft be used outside of the continental
[ ] Yes [ ] No
United States? (If “Yes”, list countries.)
Is the applicant the only user of the aircraft? [ ] Yes [ ] No
Does the applicant maintain a flight operations manual?
[ ] Yes [ ] No
(If “Yes” please submit a copy.)
Is there a full time safety management program in place for
[ ] Yes [ ] No
aircraft operations? (If “Yes” please submit a copy.)
Has applicant signed any agreements or contracts assuming
liability of others in respect to aircraft operations? (If “Yes” [ ] Yes [ ] No
please submit a copy.)
Pilot 1 Information
Address of Flight Department:
Year Flight Department w as Established:
Name of Chief Pilot:
Number of Years Employed by Applicant:
Does applicant use contract pilots, flight attendants or
[ ] Yes [ ] No
mechanics? (If “yes” describe use.)
Are any aircraft operated single pilot?
(If “Yes” answer the following and explain where necessary.) [ ] Yes [ ] No
Have w eather minima for single pilot operations been
[ ] Yes [ ] No Ceiling Visibility:
established?
Estimated number of hours for single pilot operations
per year
Pilot 2 Information
Address of Flight Department:
Year Flight Department w as Established:
Name of Chief Pilot:
Number of Years Employed by Applicant:
Does applicant use contract pilots, flight attendants or
[ ] Yes [ ] No
mechanics? (If “yes” describe use.)
Are any aircraft operated single pilot?
(If “Yes” answer the following and explain where necessary.) [ ] Yes [ ] No
Have w eather minima for single pilot operations been
[ ] Yes [ ] No Ceiling Visibility:
established?
Estimated number of hours for single pilot operations
per year
Pilot 3 Information
Address of Flight Department:
Year Flight Department w as Established:
Name of Chief Pilot:
Number of Years Employed by Applicant:
Does applicant use contract pilots, flight attendants or
[ ] Yes [ ] No
mechanics? (If “yes” describe use.)
Are any aircraft operated single pilot?
(If “Yes” answer the following and explain where necessary.) [ ] Yes [ ] No
Have w eather minima for single pilot operations been
[ ] Yes [ ] No Ceiling Visibility:
established?
Estimated number of hours for single pilot operations
per year
ATTACH PILOT QUESTIONA IRE FOR MORE PILOTS (Including contract pilots)

Maintenance Operations – Explain All “yes” answers

Names and locations of vendors providing following service (include agreement, if available)

Page 2 of 4
NA-TAC 11/09 DJWAIRL-01
Hangaring [ ] Agreement Attached [ ] No Agreement
Fueling [ ] Agreement Attached [ ] No Agreement
Airframe Maintenance [ ] Agreement Attached [ ] No Agreement
Engine Maintenance [ ] Agreement Attached [ ] No Agreement
Avionics Maintenance [ ] Agreement Attached [ ] No Agreement

Does applicant employ its’ own maintenance staff? [ ] Yes [ ] No

If yes, Name of Maintenance Director:
Have your maintenance personnel completed the manufacturer’s
[ ] Yes [ ] No
maintenance program? (If “Yes” describe)
Do your maintenance personnel receive any recurrent training?
[ ] Yes [ ] No
(If “Yes” describe)
Do your maintenance personnel service, maintain or repair
[ ] Yes [ ] No
aircraft belonging to others? (If “Yes” describe)

Description of special or extra equipment installed on aircraft and spares inventory

Aircraft Special Equipment: Value:
Spare Parts Inventory: Value:
Spare Engines: Value:
Non-Owned Aircraft Operations – Explain All “yes” answers
Do any employees (including pilots employed by the applicants’
flight department) operate or use aircraft not ow ned by the [ ] Yes [ ] No
applicant on applicants’ business?
Are employee personal aircraft used on applicant’s behalf? [ ] Yes [ ] No
Does the applicant charter aircraft for company business? [ ] Yes [ ] No
Does the applicant have w ritten directives regarding use, rental or
[ ] Yes [ ] No
chartering of non-ow ned aircraft?
Non-ow ned aircraft annual number of flights:
Does applicant ow n, rent or lease any other aircraft? [ ] Yes [ ] No
Premises – Explain All “yes” answers
Home base address:
Is the aircraft hangered? [ ] Yes [ ] No
Hangar is: [ ] Ow ned [ ] Leased/Rented Name of Landlord:
Are other aircraft (not ow ned/leased/operated by the applicant
stored in the same hangar? (If “Yes” describe) [ ] Yes [ ] No
Does the applicant fuel, hangar, tie-dow n or move any aircraft
[ ] Yes [ ] No
belonging to others? (If “Yes” describe)
Does the applicant ow n or operate its’ ow n fuel farm? (If “Yes”
[ ] Yes [ ] No
describe)
Insurance and Claims History
Has applicant had any accidents, incidents or claims? [ ] Yes [ ] No (Explain “Yes” below or on reverse side)
Has any insurance company or underw riter at any time declined
an application submitted by or canceled or refused to renew any
[ ] Yes [ ] No (Explain “Yes” below or on reverse side)
aviation insurance policy held by the applicant or any of your
pilots?

Page 3 of 4
NA-TAC 11/09 DJWAIRL-01
 Remarks

I/We certify all statements or representations contained on all pages of this application are true and correct and that I/We have read, understand and agree
with all particulars contained herein and that no material information has been withheld. I/We agree that the terms and conditions of this application and policy
currently in use by the insurers shall be the basis of any contract between me/us and the insurance company.

I/We further agree that the insurance company or their representatives, at their option, but without obligation to do so, may investigate to the extent I deem
necessary, any qualifications or statement contained in this application. I/We further confirm that unless otherwise stated i n this application, no property
described herein has any unrepaired damage as of the effective date of this application and that I/We are the sole and uncond itional owners of the property.

I/We authorize Arthur J. Gallagher Risk Management Services, Inc. to represent me/us in placing this insurance.

Date Applicant’s Signature

Page 4 of 4
NA-TAC 11/09 DJWAIRL-01
 NOTICE TO APPLICANTS

Any person w ho know ingly and w ith 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, w hich is a crime and subjects that person to criminal and civil penalties (In Oregon, the aforementioned actions
may constitute a fraudulent insurance act w hich may be a crime and may subject the person to penalties). (In New York, the civil penalty is
not to exceed five thousand dollars ($5,000) and the stated value of the claim for each such violation). (Not applicable in A L, AR, AZ, CO,
DC, FL, KS, LA, ME, MD, MN, NM, OK, PR, RI, TN, VA, VT, WA and WV ).

APPLICABLE IN AL, AR, AZ, DC, LA, MD, NM, RI and WV

Any person w ho know ingly (or w illfully in MD) presents a false or fraudulent claim for payment of a loss or benefit or w ho know ingly (or
w illfully in MD) presents false information in an application for insurance is guilty of a crime and may be subject to fines or confinement in
prison.

APPLICABLE IN COLORADO
It is unlaw ful to know ingly provide false, incomplete, or misleading facts or information to an insurance company for the pur pose 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 w ho know ingly 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 w ith regard to a settlement or
aw ard payable from insurance proceeds shall be reported to the Colorado Division of Insurance w ithin the department of regulatory
agencies.

APPLICABLE IN FLORIDA and OKLAHOMA

Any person w ho know ingly and w ith 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 FL, a person is guilty of a felony of the third degree).

APPLICABLE IN KANSAS
Any person w ho, know ingly and w ith intent to defraud, presents, causes to be presented or prepares w ith know ledge or belief that it w ill be
presented to or by an insurer, purported insurer, broker or any agent thereof, any w ritten statement as part of, or in support of, an
application for the issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other
benefit pursuant to an insurance policy for commercial or personal insurance w hich such person know s to contain materially fa lse
information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material
thereto commits a fraudulent insurance act.

APPLICABLE IN MAINE, TENNESSEE, VIRGINIA and WASHINGTON

It is a crime to know ingly provide false, incomplete or misleading information to an insurance company for the purpose of def rauding the
company. Penalties may include imprisonment, fines or a denial of insurance benefits.

APPLICABLE IN MINNESOTA
A person w ho files a claim w ith intent to defraud, or helps commit a fraud against an insurer, is guilty of a crime.

APPLICABLE IN PUERTO RICO

Any person w ho know ingly and w ith the intention of defrauding presents false information in an insurance application, or presents, helps, or
causes the presentation of a fraudulent claim for the payment of a loss or any other benefit, or presents more than one claim for the same
damage or loss, shall incur a felony and, upon conviction, shall be sanctioned for each violation by a fine of not less than five thousand
dollars ($5,000) and not more than ten thousand dollars ($10,000), or a fixed term of imprisonment for three (3) years, or both penalties.
Should aggravating circumstances be present, the penalty thus established may be increased to a maximum of five(5) years, if extenuating
circumstances are present, it may be reduced to a minimum of tw o (2) years.

APPLICABLE IN VERMONT
Any person w ho know ingly presents a false statement in an application for insurance may be guilty of a criminal offense and may be
subject to penalties under state law .