Pre-Underwriting Questionnaire Form

Complete form in entirety filling in all blanks. Then sign and date at the bottom of the form.

Named Insured(s)*:

Street Address 1:

Street Address 2:

City, State, Zip:

Aircraft / Registration #:

Insured Value:

Desired Limit of Liability:

Use (% Part 91-% Part135):

Aircraft Utilization - Hours Flown This Year (if any):

Primary Contact:

Email Address*:

Office Phone:

Best Fax:

Mobile Phone*:

Base Airport:

Hangared / Tied Out:

Expected Hourly Utilization for the Coming Year:

QUESTIONS: (Attach an additional sheet if needed)

1) Does the aircraft have a lien (Lender)? If so, who and what is the amount?

2) Current list of pilots for the aircraft (each pilot should complete a pilot form):

3) How many trips have been made outside the Continental United States during the past 12 months. What were the destinatons and
approximate lengths of stay of each trip?

4) Number of times Insured has chartered or used other non-owned aircraft (including helicopters and balloons) during the past 12 months,
including type of aircraft, approximate number of hours used, purpose of trip and destination(s):

5) Is Named Insured a holding company? For who (Beneficial user/owner)?

6) Please describe the business interests of the beneficial user/owner?

7) How long has the Insured or beneficial user/owner owned or operated aircraft?

8) How long has the Insured or beneficial user/owner owned and operated this aircraft?

9) Are there any single pilot operations of the aircraft? If so, please explain in detail:

10) Do the pilot or pilots fly for anyone else or any other aircraft? If so, please explain in detail:

11) Are pilots Employees (W2) of the Named Insured?

12) If pilots are not Employees of the Named Insured, are they employed by others, or are they direct Independent Contractors (1099)?

13) Are there any pilots who have any ownership interest in the aircraft or have non-aviation employee duties? If yes, please explain in detail?

14) Has the Named Insured or anyone directly involved in the operation, maintenance, or management of the aircraft had any claims, accidents,
waivers, or violations in the last five years? Please explain any yes answers in detail (you may use another sheet of paper for more space if
needed):

15) Month / year of most recent Aircraft Airworthiness (Annual) Inspection:

16) What is the average passenger load and what percentage are Employees vs. Guests?

17) When and where was the last make and model training for each pilot done and when is the next training planned?

18) What Maintenance is performed in-house and by whom? What types of Maintenance are outsourced, and to whom?

Additional Space for answers (also may attach additional sheet):

By signing below I warrant the truth of my responses and that nothing material has been withheld or suppressed.

Person completing this form:

Date of Signature:

Signature:

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