Fixed Base Operators Insurance Questionnaire

Company
 *
Last Name
*
First Name
*
Street Address
*
City
 *
State *
Zip *
Work Phone
*
Home Phone
*
E-mail
 *
Fax
 *
Airport
 *
Years in Business
*
Present Insurance Company
*
Expires Month/Day/Year
*
Aircraft Coverage
Liability Limits: *
 
Medical Coverage Each Passenger: *
Additional Coverage: *
 
  
Aircraft Schedule
For Uses R= Rental/Instruction, C= Charter
      Uses
FAA # Year Make & Model Value R/C Other
* * * *
*
* * * *
*
* * * *
*
* * * *
*
* * * *
*
* * * *
*
* * * *
*
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*
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Pilot Warrant
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: *
Premises Medical Coverage: *
Hangarkeepers Liability Limits: *
 
 
Fixed Base Operations
General Information
Applicant occupies: *
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: *
 
Any other locations at other airports occupied by the applicant: *  
Are Ultralight, Parachuting or Agriculture operations conducted on the premises: *

Number of vehicles owned/used by applicant: Fuel Trucks: * Tugs:*
Has applicant had any airport related losses/claims during last 5 years: *

If yes, explain: *
Has any insurer canceled declined or refused to renew any aviation insurance: *

If yes, explain: *
 
Fueling
Type of Fuel Sold:
Jet Fuel: * gallons Avgas: * gallons Auto Fuel: * gallons
Type of Fuel Storage: *

Fuel is dispensed from: *


 Maintenance
Type of Aircraft Maintained: *

Do you Overhaul of Manufacture: *

Other things you want us to know about your operation:
*