May 19, 2012
Insurance Coverage, Inc.

Airport Liability Application

Airport Liability Application

Applicant Information
Applicant's Name:
Mailing Address:
Effective Date:
12:01 am standard time at the address above.
Expiration Date:
12:01 am standard time at the address above.
Applicant is: Government
Corporation
Partnership
Estate
Other
If Applicant is a Partnership, Please Name All Partners:
General Information
Name & location of this Airport (this application is only for one airport location)
Applicant interest in Airport is: Owner  Lessor
Applicant is: Lessee  Trustee  Other
a) Does airport board/authority/commission or transportation authority operate airport? Yes  No
b) Does applicant submit airport insurance for public bid annually? Yes  No
c) Does applicant maintain insurance for all other non-airport operations through commercial insurance carriers? Yes  No
(If YES to above) show limits ($):
If yes to "c", show expiration date:
If yes to "c", show deductible/S.I.R. ($):
If no to "c", describe program fully:
d) Airport Budget Last Year ($):
d) Airport Budget This Year ($):
FAA Airport Classification:
Airport Altitude:
List certificate restrictions and exemptions:
Premises - Operations
Control Tower Operation: No Control Tower
FAA Tower
Other - Operated By:
Operating Days/Hours are:
Applicant (Does/Does Not) Operate Unicom Service: Does  Does Not
Are any Navaids, Radars, Windshear detectors or aircraft communications owned, leased or maintained by applicant? Yes  No
Describe:
Runways, Taxiways, Ramps inspected/maintained by: Applicant  Other - Name of Firm:
Does applicant maintain/operate fuel storage facilities? Yes  No
If "yes" to the above question, are the tanks above ground or below ground? above ground  below ground
How frequently are the fuel tanks inspected?
Non-Aviation activities on Airport: Lodging
Industrial Park
Storage
Farming
Other - Describe All Non-Aviation Activites
Premises - Operations (Continued)
a) Maintain Air Crash Emergency Plan? Yes  No
b) Maintain Anti-Terrorist Plan? Yes  No
c) Employ Medical Personnel? Yes  No
c - part 2) Do they have separate insurance coverage? Yes  No
What is the distance (miles) to nearest Fire Department?
d) Base Fire Fighting vehicles on the Airport full time? Yes  No
e) Maintain Wildlife and Bird Strike prevention program? Yes  No
f) Own, operate, use or maintain any off-Airport premises to be covered? Yes  No
(If YES above) Describe all locations and uses:
g) Charge for auto parking? Yes  No
Number of Parking Spaces:
h) Host/sponsor or operate Airshows? Yes  No
(If YES above) Describe:
i) Number of elevators?
i - part 2) Number of escalators?
i - part 3) Number of Moving Sidewalks?
1 - part 4) Number of automated passenger trains?
i - part 5) Number of Automatic Doors?
i - part 6) Who maintains the previously mentioned?
a) Airport security is provided by:
b) Frequency of patrols:
b - part 2) Do they have separate insurance coverage? Yes  No
(If YES above) Please describe:
c) Is airport completely fenced in? Yes  No
a) General aviation:
b) Commuter airlines:
c) Military:
TOTAL:
Estimated number of enplaned passengers this year:
Largest Aircraft using Airport (Include Make and Model and Name of Operator):
List all Air Carriers using the Airport:
Hangarkeepers Liability
Aircraft in your custody for storage/safekeeping/repair/servicing)
a) No. of hangars
b) No. of tie-down/parking spaces
c) Describe each hangar (show age, construction materials, size & if sprinklered)
d) Average value any one aircraft ($)
d - part 2) Average total ($)
e) Maximum value any one aircraft ($)
e - part 2) Total all aircraft ($)
f) Maximum value of any one hangar ($)
f - part 2) Maximum value of any one tie-down ramp ($)
g) Gross sales for hangar rental/lease last year ($)
g - part 2) Gross sales for hangar rental/lease estimated for this year ($)
g - part 3) Gross sales for tie down rental/lease last year ($)
g - part 4) Gross sales for tie down rental/lease estimated for this year ($)
Contruction, Demolition & Alterations
Contract costs this year for:
By Applicant - Runways ($)
By Applicant - Other ($)
By Applicant - Describe Work
By Independent Contractors - Runways ($)
By Independent Contractors - Other ($)
By Independent Contractors - Describe Work
Is there an owners controlled insurance program? Yes  No
If there is an owners controlled insurance program, what is the limit ($)?
If there is no owners controlled insurance program, what is the minimum limit required of independent contractors ($)?
Is applicant included as additional insured? Yes  No
Current Insurance
Name of Insurance Company:
Expiration Date:
Coverages:
Limits:
Deductible ($):
Premium ($):
Coverges & Limits Requested
Commercial General Liability Coverage
  Limits of Insurance ($)
General Aggregare Limit (other than products/completed operations)
Products/Completed Operations Aggregate Limit
Personal and Advertising Injury Aggregate Limit
Each Occurance Limit
Fire Damage Limit (any one person)
Medical Expense Limit (any one person)
Coverages & Limits Requested
Hangarkeeper's Liability Coverage
Each aircraft Limit ($)
Each Loss Limit ($)
Deductible - Each aircraft ($)
Total Advance Premium ($)
Policy Deductible
Each Occurance $:
Annual Aggregate $:
Other coverages, restrictions, endorsements:
Applicants Vehicles
Identify the number of vehicles owned by, operated by or leased to applicant:
Snow Removal Equipment
Fuel Trucks
Sweepers
Tugs
Crash-fire-rescue vehicles
Hydrant Carts
Passenger Cars
Pickup Trucks
# of Passenger buses 30 seats and under
# of Passenger buses over 30 seats
List Other Vehicles
Describe any operation of vehicle off airport premises
Does applicant maintain automobile liability coverage Yes  No
If the applicant does maintain automobile coverage, what is the limit?
Non-Owned Aircraft
Provide following information with respect to non-owned aircraft operated by or on behalf of the airport:
Does airport use non-owned aircraft on airport business? Yes  No
If "yes" to the previous question, do employees pilot aircraft on airport business? Yes  No
Describe types of aircraft flown on airport business:
* = Required Field
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