Southwest Aviation Insurance

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Contact Last Name
First Name
  
Company Contact Occupation  
Street Address
City
  
State
Zip 
     
Phone Work
Home
  
Email
Fax
  
Airport
Years in Business
 
Present Insurance Company
Expires MM/DD/Year
 

Liability and Medical Coverages

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
Uses(select all that apply)
FAA #
Year Make & Model
Value
Rental
Charter 
 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 Insurance Coverage

Airport General Liability Limits

$500,000 Combined Single Limit
$1,000,000 Combined Single Limit
$ Combined Single Limit

 

Products Liability Limits

$500,000 Combined Single Limit
$1,000,000 Combined Single Limit
$ Combined Single Limit
 

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
Premises Medical Coverage $1,000 $2,500 $5,000 Each Person
 

Fixed Base Operations

General Information

 
Applicant occupies Office Square Feet

Applicant occupies Hangar #1 Square Feet        Hangar #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 and volume 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
Which of the below do you overhaul or manufacture?  
Engines Propellers Kit Planes Accessories
Other Comments or Questions:
 
 

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