Airport Insurance Quote

Call 1-877-386-2601

Special Deals on
Auto & Homeowners
Insurance For Pilots
By Balliet

Airport Liability Insurance Application

Required Fields
Owner Information

First Name		Last Name
Company Name		Company Type
Airport Name		Applicant is
Located	Miles	From City
Address		City
State		Zip Code
Day Phone#		Night Phone#

Email Address_________________________

Liability Coverage-state limits of liability desired
___________________________________________________________

Bodily injury Combined single limit	Property damage	Each occurrence
Hangarkeepers liability	Each aircraft	Each occurrence
Personal injury liability	Each person	General aggregate

___________________________________________________________
Airport Description

Elevation is	Longest runway
# Of aircraft based at airport	Airline	General Military
Runway construction	Are runways lighted
Air traffic is controlled	By	Operated by
Is there an airport manager?	Employed by
Is Manager on premises during hours of operation?	Hours of operation	from To

Does the insured own, operate or maintain any aids to navigation?
If yes to above please describe in box below

If The applicant is owner or general lessee - Complete the following and fax a map or FAA form 5010-1 to 1-570-386-4385.

Airport manager is
If Independent contractor (Fax copy of contract to 1-570-386-4385)

Any Recreational or Non-Aviation facilities or use of airport premises
If yes please describe in box below

________________________________________________________
Operations Of Applicant
Indicate all operations and estimated gross receipts per year.

Fuel & Lubricants		Tiedowns & Hangaring
Landing Fees		New Aircraft
Used Aircraft		Aircraft Parts
Aircraft Repair		Aircraft Charter
Rental & Instruction		Helicopter Repairs
Restaurant		Auto Parking

List all other sources and receipts in the box below.

___________________________________________________________
Tie Down & Hangaring by Applicant
___________________________________________________________
Are Aircraft of others taxied, towed or moved by applicant

Number of tiedowns	Spaces	T-hangars	Multiple hangers
Types of tiedowns
# of aircraft	Tied down	In T-Hangars	In multiple hangers
Highest Value of Aircraft	Tied down	In T-Hangars	In multiple aircraft hangers
Total Value of all Aircraft	Tied down	In T-Hangars	In multiple aircraft hangers

Additional Information

We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By Clicking Submit below you agree to allow our agency to release this information via the method you have chosen, and to release us from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy.

BALLIET INSURANCE AGENCY, INC.
Telephone: 1-877-386-2601
FAX: 1-570-386-4385
Postal address: 1403 Blakeslee Blvd. Lehighton, PA., 18235
Electronic mail: General Information: johntag@ptd.net