Fixed Base Operators Insurance

Fixed Base Operators Insurance Questionnaire

 

Company  
Last Name First Name  
Street Address  
City State Zip
Phone Work Home  
Email Fax  
Airport Years in Business
Present Insurance Company Expires Month/Day/Year
         
Aircraft Coverage
Liability Limits: $500,000 Combined Single Limit with $100,000 per passenger
  $1,000,000 Combined Single Limit with $100,000 per passenger
  $1,000,000 Combined with no per passenger limitation
  $ Million Combined Single Limit with no passenger limitation
         
Medical Coverage Each Passenger $1,000 $3,000 $5,000
       
Additional Coverage Student/Renter Pilot Liability Non-Owner Liability
  Non-Owned Hull Coverage $ each aircraft

 

Aircraft Schedule
 
* For Uses R= Rental/Instruction, C= Charter
USES
FAA # Year Make & Model
Value
R    C    OTHER

 
Pilot Warranty

Your current pilot warranty or what you would like to request
Fixed Tricycle Gear <201 HP
Fixed Tricycle Gear >200 HP
Tailwheel Gear <201 HP
Tailwheel Gear >200 HP
Retractable Gear <201 HP
Retractable Gear >200 HP
Multi-Engine <501 Total HP
Multi-Engine >500 Total HP
Rotor Wing
Gliders
Aircraft Losses Past 5 Years
Airport Coverage
Airport General Liability Limits
Products Liability Limits
$500,000 Combined Single Limit $500,000 Combined Single Limit
$1,000,000 Combined Single Limit $1,000,000 Combined Single Limit
$ Combined Single Limit $ Combined Single Limit
       
Premises Medical Coverage $1,000 $2,500 $5,000 Each Person
       
Hangarkeepers Liability Limits $50,000 Each Aircraft, $100,000 Each Occurrence
$100,000 Each Aircraft, $300,000 Each Occurrence
  $250,000 Each Aircraft, $500,000 Each Occurrence
  $ Each Aircraft, $ Each Occurrence
FIXED BASE OPERATIONS
General Information
Applicant occupies :  
Office Square Feet  

Hangar(s) #1 Square Feet #2 Square Feet
Total number of tie-downs on your premises  
Average Value of Aircraft tied out $  
Number of aircraft hangared Average Value of Aircraft Hangared $
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 applicant had any airport related losses/claims during last 5 years Yes No
If yes explain
Has any insurer canceled, declined or refused to renew any aviation insurance Yes No
If yes explain
     
Operations Information
Types of services provided by applicant and gross receipts for each operation
Fueling $ Maintenance $
Parts Sales $ Avionics $
Aircraft Sales $ Other $
Fueling
Type 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 of Manufacture:  
Engines Propellers Kit Planes Accessories
Other things you want us to know about your operation

 

 

Southwest Aviation Insurance Group
Mark Nichols
 
Dave Monaco
14415 N. 73rd Street, Suite 115
Scottsdale, AZ 85260
800-324-6787           Fax 480-483-8299