Aviation (HKL) Liability Insurance Proposal Form (Premises, Hangarkeeper’s and Products Liability) Contact details Period of Insurance Describe your aviation business or aviation operation actives in full How long have you been in business? Do you have operation outside of Australia? YESNO if yes, please advice where Premises Liability Liability for bodily injury or property damage to third parties (a) In or about your premises as a direct result of the services granted by you (b) elsewhere in the course of any work or of the performance of any duties carried out by you or your employees in connection with your business or operations caused by the fault or negligence of you or any of your employees engaged in your business or by any defect in your premises, ways, works, machinery or plant used in your business. What is the full address of the premise(s): Are there any other persons or organisations requiring to be named as an additional Insured? YESNO If yes, please advise their name and interest: Are you responsible for any fuel storage facilities? YESNO If yes, please provide full details including estimate of litres of fuel sold per annual Do you sell any food or drinks? YESNO If yes, please advise your annual turnover: Do you own, lease or occupy any premises airside? YESNO If yes, please List and identify the premises you own, occupy or lease Premises OwnLeaseOccupy Premises OwnLeaseOccupy Premises OwnLeaseOccupy Is the proposer responsible for maintenance of any airfield / airport? Do you own or operate any mechanically propelled vehicles, mobile plant or ground service equipment airside? YESNO If yes, please provide a full list of the vehicles: Do you host, sponsor or operate any Air Shows or Air Meets? YESNO If yes, please provide full details: Do you or any of your directors or employees temporarily travel overseas on behalf of the Insured's business? YESNO If yes, please provide details of overseas countries these persons will visit and advise the estimated number of days they will be away from Australia: Hangarkeeper’s Liability Loss of or damage to aircraft or aircraft equipment, not owned, rented, operated or leased by you, whilst on the ground in the care, custody or control of or whilst being serviced, handled or maintained by you or your employees. Do you ever have non-owned (third party) aircraft or equipment in your care, custody or control at any of the premises named above? YESNO If yes, please provide the following details: What typical types (make and model) of aircraft, aircraft parts or equipment (engines etc.) do you have in your care? What is the usual total value of such aircraft or equipment? What is the maximum value of any one aircraft? What is the maximum value of any equipment at any one time? Do you wish to extend the policy cover to include liability whilst any such aircraft is in flight? (i.e. a test flight): YESNO If yes, please indicate the minimum experience of any pilot that may fly such aircraft: Products Liability Bodily injury or property damage arising out of the possession, use, consumption or handling of any goods or products manufactured, constructed, altered, repaired, serviced, treated, sold, supplied or distributed by you or your employees, but only in respect of such goods or products which form part of, or are used in conjunction with aircraft, and then only after such goods or products have ceased to be in your possession or under your control. What is the nature of the work you do, or what aircraft or parts or equipment do you sell? Describe the experience and general training levels of your aviation personnel: Do you provide fuel to third parties as part of your aviation operations? YESNO If yes, please provide full details e.g. type of fuel, type of aircraft and annual litreage: What type of aircraft or aviation equipment do you work on? (Fixed Wing, Rotor Wing, Engines, Propellers, etc.) Do you represent / are you an agent for any manufacturer(s) of aviation products? YESNO If yes, please give details: Do you use any subcontractors? YESNO If yes, please give details of the work performed by them: Do you wish to include their liability for services provided to you by them under your insurance? YESNO If yes, please give details: Do you do any business with customers or agents domiciled in the USA? YESNO If yes, please provide details: Please estimate your gross annual revenues: Last Year (Actual) This Year (Estimate) Labour Charges Parts / Sold / Installed Subcontracted Work What was the split between last years annual revenues? Piston Turbine Fixed Wing Rotor Wing Subcontracted Work Fuel Sales Manufacturing Other Staff Information (no of Staff) Management Office Staff Engineering LAME Engineering Other Sales Other Number Liability Limits Required (Please advise if Insured currency is other than Australian Dollars) Premises Liability any one occurrence Hangarkeeper’s Liability any one occurrence Products Liability any one occurrence and in the annual aggregate Questions applicable to all Sections Have you to the best of your knowledge and belief entered into contractual liability which imposes a liability upon you to which you would not have been otherwise subject? YESNO If yes, please provide details (including copies of any contracts): Claims / Loss History Please give details of all claims, losses or incidents involving damages, liabilities or other losses associated with any aircraft in which you have been involved in the last 5 years: Regulatory History Have you or any partner / director / employee of the business / operation ever been convicted of any breach of Civil Aviation Orders or Air Navigation Regulations or any other regulation governing the conduct of the business / operation? YESNO If yes, please provide details: Previous Insurance Have you personally or as a director or partner of a company held General Liability or Aviation (HKL) Liability Insurance? NOYES If yes, please provide the following details: Have any insurance policies ever been cancelled, declined or renewal refused? NOYES If yes, please provide the following details: Other Information Please provide any other information which you feel may be relevant to this proposal: As part of our ongoing commitment to the environment and to deliver faster and more efficient communication with our clients, we are aiming to send all future correspondence electronically. However, if you would prefer to receive a hard copy of correspondence including underwriters’ policy documentation and invoices, please tick the box below. I / We would prefer to continue to receive hard copies of all documentation Signing this proposal form does not bind you to complete the Insurance but it is agreed that this form shall be the basis of the contract should a Policy be issued. I/We hereby declare that the foregoing particulars are true and complete to the best of my/our knowledge and belief and I/we agree that this declaration and the answers given herein and any other written statement made by me/us or on my/our behalf for the purpose of the proposed insurance shall be the basis of, and incorporated in, the contract between me/us and the Insurer. Date: [datedate class:two-third class:two-third-last class:av-txt] After completion, please save this form and then email to firstname.lastname@example.org The liability of the Insurer does not commence until acceptance of the Proposal and cover is confirmed.