Aircraft & Parts Manufacturers Application

If you would like to request an online quote please complete the form below. This information is for internal use only; none of the following will be distributed to any other parties. See our privacy statement for more information.

*Name of Insured:

Street Address:

*City:

Province:

Postal Code:

*Please provide Email Address or Day Phone:

Email Address:

Day Phone:

Fax:

Individual Corporation Co-Partnership

Name and addresses of all subsidiary corporations to be covered:

Limits of Liability

Single Limit Bodily Injury and Property Damage Liability

Per Occurrence		Aggregate

$		Same

Alternatively

$		Same

$		Same

20% of Above Limit of Liability

Include Grounding:

Estimated Sales

Non-Military Aircraft Products

		Next 12 Mo. Ending		Current 12 Mo. Ending		Prior 12 Mo. Ending		Prior 12 Mo. Ending



Airframes, Engines and Propellors	$		$		$		$

Supersonic Transport and Widebody Aircraft Parts	$		$		$		$

Rotary Wing Sales	$		$		$		$

All Other Non-Military	$		$		$		$

Military Aircraft Products

		Next 12 Mo. Ending		Current 12 Mo. Ending		Prior 12 Mo. Ending		Prior 12 Mo. Ending



Missile and Missile Parts	$		$		$		$

Fixed Wing Airframes, Engines and Propellors	$		$		$		$

Rotary Wing Sales	$		$		$		$

All Other Military	$		$		$		$

Spacecraft and Spacecraft Component Parts	$		$		$		$

Policy Period

From:	/ /
To:	/ /

Business of the Named Insured (manufacturer, installations, servicing, etc.):

State the nature and describe the aircraft products manufactured or sold by the Named Insured or its subsidiaries:

State the experience or length of time involved in manufacturing or selling each product:

Describe what warranties are provided on such aircraft products:

Describe testing and engineering controls used to maintain quality of aircraft products:

Names of your larger customers to whom such products are sold:

Have you had any product losses? Is so, give details:

Name of last product insurance carrier:

Please let us know how you heard about us:

Other:

To the best of the knowledge or belief of the undersigned, no executive officer of the Insured knows of any feature of any aircraft product covered hereby that could require it, in his judgement, to be grounded or replaced as unsafe, and with respect ot which remedial action has not been or is not being taken:

If this form is being filled out by a broker, please fill out the following information.
Name of Brokerage:
Contact:
Phone #:
Email address: