8722 S. Harrison St. Sandy, UT P.O. Box 4439 Sandy, UT Fax

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1 8722 S. Harrisn St. Sandy, UT P.O. Bx 4439 Sandy, UT Fax HANGAR General Infrmatin Prpsed Effective Date: Applicant s Name: Applicant s Mailing Address: Cunty: Business Telephne Number: ( ) Fax: ( ) Physical Lcatin f Business (if different): Other Lcatins Used: Physical Address: Physical Address: Is this a new business? Yes N If n, hw many years have yu been in business? Under this management At this lcatin: Number f emplyees: Applicant is: Individual Crpratin Partnership Gvernment Bdy Estate Other Other (please describe): 1. 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 r any predecessr r related persn r entity ever had a claim? Yes N Cmpleted Claims and Lss Histry frm attached (REQUIRED)? Yes N Has the Applicant, r anyne n the Applicant s behalf, attempted t place this risk in standard markets? Yes N If the standard markets are declining placement, please explain why: 2. Desired Insurance Please check all that apply: Hangar Liability Owned Aircraft Hangar Keeper s Legal Liability (HKLL) Cntracted Prperty Damage: legal liability fr aircraft n sale EIBI-A NOV2005 Page 1 f 5

2 Liability Insurance: Physical Damage t nn-wned aircraft used fr business nly. DOL Limit f Liability: Hangar Liability $25,000/$75,000 $200,000/$400,000 $50,000/$100,000 $250,000/$500,000 $100,000/$200,000 $500,000/$1,000,000 $150,000/$300,000 Self Insured Retentin (SIR): $1,000 (Minimum) $1,500 $2, Business Activities $5,000 $10, List all lcatin(s) wned r frm which yu perate (use separate sheet if necessary). Please list address, city, state and descriptin f use. Shw main lcatin as number 1. Lc. 1 Lc. 2 Lc. 3 NUMBER AND STREET CITY COUNTY STATE ZIP CODE 2. Descriptin f use fr each lcatin listed: Lc. 1: Type f Facility: Hangar Strage Standard Tie-Dwn Ramp (Prtected Psts/Chains) Lc. 2: Nn-Standard Tie-Dwn Ramp (Unprtected) Type f Facility: Hangar Strage Standard Tie-Dwn Ramp (Prtected Psts/Chains) Lc. 3: Nn-Standard Tie-Dwn Ramp (Unprtected) Type f Facility: Hangar Strage Standard Tie-Dwn Ramp (Prtected Psts/Chains) Nn-Standard Tie-Dwn Ramp (Unprtected) Please specify yur annual grss receipts fr each f the fllwing categries: Actual Sales Prjected Next 12 Mnths Physical Repair (Aircraft Bdy) f Aircraft - Grss Incme $ _ $ _ Sales f Aircraft Parts and Supplies - Grss Sales $ $ Used Aircraft Sales - Grss Sales $ $ New Aircraft Sales - Grss Sales $ $ Leased Aircraft Sales - Grss Sales $ $ Gasline - Gallns Sld $ $ Strage f Aircraft - Grss Incme $ $ Mechanical Repair and Service t aircraft -tune-up, air cnditining, lube and il, brakes, engine rebuilding- Grss Incme $ $ Experimental r Hmebuilt/Ultralight Aircraft Repair, - Grss Incme $ $ EIBI-A NOV2005 Page 2 f 5

3 Rental f Aircraft - etc.-grss Incme $ $ Tire Sales and Service-Grss Sales $ $ Parking-Grss Sales $ $ All Other Incme-Explain $ $ Retail Sales $ $ Ttal Grss Receipts frm all peratins $ $ 3. Describe test flight prcedures: 4. Is anyne ther than emplyees allwed t wrk n aircraft n premises? Yes N 5. Lts: a. If Aircraft is utside, is lt cmpletely enclsed by a chain link fence r chain and psts nt mre than fur feet apart? Yes N Nt mre than six feet apart? Yes N b. Is lt cmpletely fldlighted? Yes N c. Is there plice r ther prtectin? Yes N d. D yu pick up r deliver Aircraft? Yes N e. D yu repssess Aircraft? Yes N If yes, please list number f repssessins annually: # 6. If yu are a whlesaler, d yu maintain a separate strage facility? Yes N If yes, please explain: 7. D yu cnsign Aircraft t sell? Yes N If yes, hw are they insured? 8. Average number f aircraft sld annually: Ttal: Retail: Whlesale: 9. Average number f aircraft fr sale at ne time: 10. Please cmplete a Schedule f Named Pilts, listing Pilts t be specifically insured (n cverage will be affrded unless all Pilts wh are authrized t use an Aircraft are listed). 11. Please cmplete a schedule f aircraft t be specifically insured. Please list all aircraft wned and licensed by yu and used in yur business. 4. HKLL - Hangar Keepers Legal Liability Max Value f any ne Unit Lc. 1 $ $ Lc. 2 $ $ Lc. 3 $ $ Max Value per Lcatin Specified Causes f Lss Fire, Theft, Explsin, Mischief and Vandalism Cllisin EIBI-A NOV2005 Page 3 f 5

4 Cntractual Prperty Damage: Legal Liability n aircraft fr sale Dealers Inventry Cverage Max Value f any ne Unit Max Value per Lcatin Lc. 1 $ $ Lc. 2 $ $ Lc. 3 $ $ Specified Causes f Lss Fire, Theft, Explsin, Mischief and Vandalism Cllisin Interests t be cvered n Aircraft held fr sale: All party s interest in cvered Aircraft Financed party s interest nly in stck fr sale LIMITS OF COVERAGE NUMBER OF UNITS In Tw/ On hk with tug $ Carg $ List nn-licensed mbile equipment: 5. Emplyee Infrmatin 1. Number f Ttal Staff: Full Time: Part Time: Seasnal: NUMBER A. Prprietr, Partner, Officer $ B. Office Emplyees $ C. Salesmen $ D. Service Dept. Emplyees $ E. Other Emplyees $ 2. Mechanic List: ESTIMATED ANNUAL GROSS PAYROLL NAME POSITION D.O.B. A&P OR IA LICENSE EIBI-A NOV2005 Page 4 f 5

5 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. 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 NOV2005 Page 5 f 5