Contact Information: 

Name        Occupation/Business     

Individual     INC     LLC     Partnership     Trust     Municipality 

Contact name (if an organization) 

 Address: Street                          City    
                  State                            Zip

         Day Phone      Alternate Phone   

                      Fax                       Email   

Years in Business    You are the Airport's Manager?   No    Yes

Portion of Airport you Occupy: Entire Airport    Leased Buildings & Ramp Area   
                                                   Other:

Insurance Information:

Present Ins. Company        Expires MM/DD/YY 

Has applicant had any losses/claims during last 5 years?    No     Yes*  
Has any insurer canceled, declined or refused to renew any aviation insurance?    No     Yes*  
*If yes, please explain: 
  

Insurance Coverages:

Airport General Liability Limits (Premises Liability)  
$1,000,000 Combined Single Limit  
$2,000,000 Combined Single Limit 
Other - Enter Amount:

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
$500,000 Each Aircraft, $1,000,000 Each Occurrence 
$1,000,000 Each Aircraft, $1,000,000 Each Occurrence 
Other - Enter Amounts: $ Each Aircraft, 
                                            $ Each Occurrence  

Premises Medical Coverage   
$3,000 per person  
$5,000 per person  
$10,000 per person 

Products and Completed Operations Liability Limits 
$1,000,000 Combined Single Limit  
 $2,000,000 Combined Single Limit  
 Other: $ Combined Single Limit 

Optional Coverages 
  On Premises Auto     Contractual Liability     Host Liquor Liability   
  Advertising & Personal Injury Liability      Incidental Locations Liability    In-Flight Hangarkeepers

Airport Information:

Airport Name:      Airport Identifier:  

Type of Airport:    Private     Public     Heliport

Is the airport/heliport fenced:   None     100%     Percent fenced  %

Type of airport security:    Airport Police     Local Police     Private Security     None

Distance to fire department:    On airport        miles from airport

Number of aircraft based at airport:  

Are there any Untralight, Parachuting or Agriculture Operations conducted on airport:   No

Yes - Explain:

Do you own/lease any buildings on the airport:  No     Yes (if yes, complete following questions)

Size of Office:  Sq Ft.   
Hangar #1: Sq Ft.       Hangar #2: Sq Ft.   
Hangar #3: Sq Ft.       Hangar #4: Sq Ft.

Total number Tie-Downs on premises:    
           Avg Value of Aircraft Tied Out:  $ 

               Number of aircraft hangared:    
 Average value of aircraft Hangared:  $   

Do you own or lease any other locations at other airports:  

Number of vehicles owned/used by applicant: 
Fuel Trucks       Tugs

Are you the airport manager:  No    Yes  

Services & Operations Information: 
Types of services provided by applicant and gross receipts for each operation (Select all that apply): 
Fueling-$         Maintenance-$     
Parts Sales-$           Avionics-$    
Aircraft Sales-$           Other-$

Number of vehicles owned/used by applicant: 
Fuel Trucks:      Tugs:  

Fuel Information:  
Type and volume (gallons) of Fuel Sold: 
Jet Fuel       AVGas     
Auto Fuel    

   Type of Fuel Storage:   Underground   Above Ground   Fuel Truck   
Fuel is Dispensed from:  Truck                Fuel Island         Self Service  

Maintenance:   
Type of Aircraft Maintained:  Single Engine   Multi-Engine   Rotorcraft   Turbine 

Which of the following do you overhaul or manufacture?  Engines   Propellers   Kit Planes  Accessories

Comments or Questions: