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Aircraft Products Liability Insurance Quote
Insured Information
Named Insured
Insured is a
Corporation
Individual(s)
Partnership
Nature of Business of Named Insured
Contact Name
Address
City
State
Telephone
Cell Phone
Fax
Email
Aircraft Products Sales Information
Estimated Sales
Next 12 months
Estimated Sales
Previous 12 Months
Non-Military Aircraft Products
Fixed Wing - Piston Aircraft
Fixed Wing - Turbine Aircraft
Helicopter
Other
Totals Non-Military
Military Aircraft Products
Missiles & Spacecraft - exclude Space Shuttle
Helicopter
Space Shuttle
All Others
Totals Military
Grand Total
Policy Period
Effective Date: 12:01 A.M.
January
February
March
April
May
June
July
August
September
October
November
December
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
2007
2008
2009
2010
Liability Limits
Products (BI) & (PD)
$
Aggregate
Grounding
$
Aggregate
Other Information
Describe the aircraft products manufactured or sold by the Named Insured or its subsidiaries 9subimt brochures or other similar material, if available), and specify the AIRCRAFT AND AIRCRAFDT SYSTEMS in which products are used
How many years have you operated under your present business name?
Describe the terms of any basic or extended warranties provided for the aircraft products that you manufacture. Submit samples copiers if available
Names of key customers to whom your aircraft products are sold
Describe testing and engineering controls used to maintain quality control of aircraft products
Do you manufacture the entire product?
YES
NO
If No, describe component part(s) source from others
Do you fully assemble the product?
YES
NO
If No, describe assembly services sourced from others
Do you maintain and/or service your products?
YES
NO
If Yes, attach full details including copy of your standard written service contract and receipts from this source
Are any of your aircraft products flammable, explosive, toxic or otherwise hazardous?
YES
NO
If Yes, attach details
Have you ever been sued or has any claim ever been made against you in connection with any of your aircraft products, whether or not such products and subject of this application?
YES
No
If Yes, provide the details and status such of claim or suit whether pending or resolved. If resolved, explain manner of such resolution
Are you aware of any incident, occurrence or circumstance involving any of the products described on this application which is likely to result in a claim against you?
YES
NO
If Yes, provide details
Have any of your aircraft products ever been subject to any inquiry or investigation by any Government Agency concerning their operation, use, adequacy or labeling, hazardous contents or safety?
YES
NO
If Yes, set forth full details and results of such inquiry
Have any of your aircraft products ever been withdrawn from the market either voluntarily by you or by order of any Government Authority?
YES
NO
If Yes, provide full details
Did you discontinue the manufacture of any aircraft product during the past 5 years?
YES
NO
If Yes, attach explanation and sales for such products by year
Are you planning to manufacture or market any new aircraft products during the next 12 months?
YES
NO
If Yes, provide full details
Have you carried Products Liability Insurance in the past?
YES
NO
If Yes, provide the insurer name, policy number and limits for coverage carried during the past 12 months
Has any Insurer cancelled, declined or refused to renew your Products Liability Insurance?
YES
NO
If Yes, provide details
Comments & Questions
Any other comments or questions
Phone: 1-818-904-9081
Fax: 1-818-904-9193
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Response Aviation Insurance Services P.O. Box 12027 Glendale, CA 91224