8722 S. HARRISON ST. SANDY, UT P.O. BOX 4439 SANDY, UT FAX

Transcription

1 8722 S. HARRISON ST. SANDY, UT P.O. BOX 4439 SANDY, UT FAX HOT AIR BALLOON PROPOSED EFFECTIVE DATE: A. General Infrmatin Applicant s Name: Applicant s Mailing Address: City: State: Zip: Business Telephne Number: Cunty: Fax: Physical Lcatin f Aircraft: Ppulatin within 50 miles f launch site: Other Lcatins Used (attach additinal sheet if required): Physical Address: City: State: Zip: States, territry, r area balln will be perated in: Applicant s Cntact Persn: Prducer s Name: Applicant is: Individual Crpratin Partnership Other (please describe): Applicant is: Aircraft Owner Aircraft Lessee Brrws r Uses Aircraft Owned by Others 1. Number f years f experience: Number f ballns t be insured: Detailed descriptin f business activities (specifically, and by lcatin): B. Insurance Histry Wh is yur current insurance carrier (r yur last if n current prvider)? Prvide name(s) fr all insurance cmpanies that have prvided Applicant insurance fr the last three years: Cverage: Cverage: Cverage: Cmpany Name Expiratin Date Annual Premium $ $ $ Has the Applicant had a claim in the last five years? If yes, please describe the circumstances f the claim: Yes N Attach a five year lss/claims histry, including details. (REQUIRED) Have yu had any incident, event, ccurrence, lss, r Wrngful Act which might give rise t a Claim cvered by this Plicy, prir t the inceptin f this Plicy? Yes N EIBI-A JAN2013 Page 1 f 5

2 If yes, please explain: Has the Applicant, r any Pilt t be insured, been cited by the FAA in the past five years? If yes, please explain: C. Desired Insurance: Hull Cverage: Basket Hull Value $ Envelpe Hull Value $ Hw determined? Hw determined? Amunt f encumbrance: Full Cverage Lan Amunt Lienhlder: Lienhlder Address: Lan Number: Lan Balance: $ Will any Lienhlder require breach f warranty cverage? Limit f Liability: $100,000 per persn / $200,000 per accident / $300,000 aggregate $100,000 per persn / $200,000 per accident / $500,000 aggregate $100,000 per persn / $500,000 per accident / $1,000,000 aggregate $100,000 per persn / $750,000 per accident / $1,000,000 aggregate $100,000 per persn / $1,000,000 per accident / $1,000,000 aggregate $250,000 per persn / $1,000,000 per accident / $1,000,000 aggregate Other: Select yur desired Self-Insured Retentin (SIR): D. Business Activities $1,000 (Minimum) $1,500 $2,500 $5,000 $10, Annual Grss Receipts: $ 3. Average cst per ride: $ Yes N Yes N 4. Is there any unrepaired damage t any f the ballns? Yes N If yes, please describe: 5. Number f passengers allwed in balln at any ne time: 6. Maximum number f ballns allwed in air at the same time: 7. Estimated number f hurs each balln will be flwn fr the next 12 mnths: (attach additinal sheets as required.) MINIMUM Balln 1 Balln 2 Balln 3 8. What, if any, are the minimum and maximum age, weight, r height requirements fr participants? EIBI-A JAN2013 Page 2 f 5

3 Age Height (in feet, inches) Weight (in punds) 9. Apprximately hw many peple participate annually? MINIMUM MAXIMUM 10. Any anticipated peratin utside the United States? Yes N 11. Number f pilts: 12. Pilt Infrmatin: Name License N. Age Type f License: Priv, Cmm, r Student # f Years Exper. Hurs Last 12 Mnths List Safety Seminar Last 12 mnths Hurs in this size balln 13. Is Applicant a member f any prfessinal rganizatins? Yes N If yes, please identify them: 14. Hw ften is balln checked and inspected? 15. D yu keep maintenance recrds? Yes N If yes, please describe: 16. Wh cmpletes required maintenance and repair wrk? Name: Fax: Service Descriptin: Business Telephne N.: Date f last service: 17. D yu have an accident/emergency plan? Yes N 18. D yu use liability waivers? Yes N If yes, please attach a cpy. 19. D yu have an perating plan r prcedures manual? Yes N If yes, please attach a cpy. E. Activity Breakdwn 20. Hw many weeks ut f the year d yu fly? 21. Hw many days d yu fly per week? Hw many rides per day? 22. %: Pleasure: Advertising: Events: Rides: 23. # f Days: Pleasure: Advertising: Events: Rides: 24. # f Passengers: Pleasure: Advertising: Events: Rides: Balln Infrmatin Year Built Make Balln #1 Balln #2 Balln #3 Balln #4 Balln #5 EIBI-A JAN2013 Page 3 f 5

4 Mdel N Number Gndla Serial N. Date Purchased New r Used? Envelpe Value *Only if cverage desired Gndla Value *if desired (includes burners, frames, and tanks) Cubic Feet Kevlar Cables? Date f Last Inspectin Inspectr s Name # f passengers excl. pilt Ttal Hurs n Balln # f Hurs per year Custm Design? Custm Artwrk? Airwrthiness Cert. Current? $ $ $ $ $ $ $ $ $ $ REPRESENTATIONS AND WARRANTIES The Applicant is the party t be named as the "Insured" in any insuring cntract if issued. By signing this Applicatin, the Applicant fr insurance hereby represents and warrants that the infrmatin prvided in the Applicatin, tgether with all supplemental infrmatin and dcuments prvided in cnjunctin with the Applicatin, is true, crrect, inclusive f all relevant and material infrmatin necessary fr the Insurer t accurately and cmpletely assess the Applicatin, and is nt misleading in any way. The Applicant further represents that the Applicant understands and agrees as fllws: (i) the Insurer can and will rely upn the Applicatin and supplemental infrmatin prvided by the Applicant, and any ther relevant infrmatin, t assess the Applicant s request fr insurance cverage and t qute and ptentially bind, price, and prvide cverage; (ii) the Applicatin and all supplemental infrmatin and dcuments prvided in cnjunctin with the Applicatin are warranties that will becme a part f any cverage cntract that may be issued; (iii) the submissin f an Applicatin r the payment f any premium des nt bligate the Insurer t qute, bind, r prvide insurance cverage; and (iv) in the event the Applicant has r des prvide any false, misleading, r incmplete infrmatin in cnjunctin with the Applicatin, any cverage prvided will be deemed vid frm initial issuance. The Applicant hereby authrizes the Insurer and its agents t gather any additinal infrmatin the Insurer deems necessary t prcess the Applicatin fr quting, binding, pricing, and prviding insurance cverage including, but nt limited t, gathering infrmatin frm federal, state, and industry regulatry authrities, insurers, creditrs, custmers, financial institutins, and credit rating agencies. The Insurer has n bligatin t gather any infrmatin nr verify any infrmatin received frm the Applicant r any ther persn r entity. The Applicant expressly authrizes the release f infrmatin regarding the Applicant s lsses, financial infrmatin, r any regulatry cmpliance issues t this Insurer in cnjunctin with cnsideratin f the Applicatin. The Applicant further represents that the Applicant understands and agrees the Insurer may: (i) present a qute with a Sublimit f liability fr certain expsures, (ii) qute certain cverages with certain activities, events, services, r waivers excluded frm the qute, and (iii) ffer several ptinal qutes fr cnsideratin by the Applicant fr insurance cverage. In the event cverage is ffered, such cverage will nt becme effective until the Insurer s accunting ffice receives the required premium payment. EIBI-A JAN2013 Page 4 f 5

5 The Applicant agrees that the Insurer and any party frm whm the Insurer may request infrmatin in cnjunctin with the Applicatin may treat the Applicant s facsimile signature n the Applicatin as an riginal signature fr all purpses. The Applicant acknwledges that under any insuring cntract issued, the fllwing prvisins will apply: 1. A single Accident, r the accumulatin f mre than ne Accident during the Plicy Perid, may cause the per Accident Limit and/r the annual aggregate maximum Limit f Liability t be exhausted, at which time the Insured will have n further benefits under the Plicy. 2. The Insured may request the Insurer t reinstate the riginal Limit f Liability fr the remainder f the Plicy perid fr an additinal cverage charge, as may be calculated and ffered by the Insurer. The Insurer is under n bligatin t accept the Insured's request. 3. The Applicant understands and agrees that the Insurer has n bligatin t ntify the Insured f the pssibility that the maximum Limit f Liability may be exhausted by any Accident r cmbinatin f Accidents that may ccur during the Plicy Perid. The Insured must determine if additinal cverage shuld be purchased. The Insurer is expressly nt bligated t make a determinatin abut additinal cverage, nr advise the Insured cncerning additinal cverage. 4. The Insurer is herein released and relieved frm any and all respnsibility t ntify the Insured f the pssible reductin in any applicable Limit f Liability. The Insured herein assumes the sle and individual respnsibility t evaluate, cnsider, and initiate a request fr additinal cverage r reinstatement f the annual aggregate Limit f Liability which may be exhausted by any single Accident r cmbinatin f Accidents during the Plicy Perid. Dated: Applicant: Dated: Agent/Brker: Signature Signature Print Name Print Name EIBI-A JAN2013 Page 5 f 5