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HomeMy Public PortalAbout2021.07.26 General Aviation Airport Insurance Questions General Aviation irport Insurance Questions e 1 Name of Applicant: Me411 Airport IdentiFier: m vi Address: Al SS 4 ti / f sa , - Airportf Name: YJne6 a 111 ici,„; 7 Located: miles (direction) of I ' n 1/ (city) Airport Manager: r,<-)( S�)..-cam Phone Number: G 3cl- . 61 LS- ` 7O '- t 3"/q/ Operations of Applicant include all operations and estimated annual gross receipts Fuel&Lubricants: S ❑ Airsho vs: s Tiedcw ns&Hangaring: •1, ti4' ) ,5 .y I Aircraft Maintenance: S Landing Fees: 5 'A 000 Aircraft Charter: 5 0 New Aircraft: s c Rental&Enstruction: s Used Aircraft: g 0 Restaurant: Aircraft Parts: g 6 Auto Parking: > Other: 3 6 For: Other: s For: Other: 5 For: Other: s For: Fueligg Fueling On Premis : 'NNiV (check if yes) Done By Applicant: (check if yes) Dispensed By: -HSO Lip Truck:`; Hydrant: Gas pump:N' Gas Pit: Other: Annual Gallonage: ,G/ 4u 7,S 5 Du Airline: General Aviation: �e).p'eti Military: Type of Fuel Sold: (check all that apply) AV Gas:" Jet Fuel: Aircraft Auto Gas: Fuel Storage Facilities: underground: gallons above ground: gallons Tie Down & Hangaring by Applicant indicate number of spaces, aircraft, and values of aircraft Number of spaces: tiedowns: S c T-hangars: multiple aircraft hangars: 0 Number of aircraft: tiedowns: T•hangars: multiple aircraft hangars: ‘'-J ' Highest value aircraft: tiedowns: T-hangars: multiple aircraft hangars: Total value of all aircraft: tiedovens: T hanoars: multiple aircraft hangars: Are aircraft of others taxied,towed, or moved by applicant> (check if ves) Applicant's Vehicles, Elevators and Aircraft indicate the number of vehicles,elevators, and aircraft maintained for use exclusively on the airport premises Fuel Trucks: Sweepers: Snow Removal: 3 Fire Engines: Tugs: Hydrant Carts: Pickup Trucks: Passenger Cars: Other: 'Z ik44.1 Elevators: Escalators: gloving Sidewalks: N-h. f Airplanes owned or operated by applicant: Helicopters: �}hJ! Contracts submit copies of any relevant contracts to intake:Mcrnip.org Has the applicant entered into any written agreements assuming the!lability of others, (check if yes) such as lease of premises, fuel supplier, equipment lease, etc? Does applicant use uniform customer contracts for hangaring, service, etc? (check if yes) Does applicant require "hold harmless" coverage? ' (check if yes) Give details of minimum limits required from: Airlines l i FBO's $I —1 Concessionaires $1 1 Is applicant named as Additional Insured? (check if yes) General Aviation Airport Insurance Questions Construction by Independent Contractors estimated cost by type of construction Runways k Taxiways 5 j',, ,'� current year $I !, 1 next year 5 j 1, 0 'next three years All others (describe) 5 I 1 current year S I I next year s L �I next three years Fixed Base Operators list names of FBO's on airport premises 4 , l . Airport Description submit airport manager independent contracts to intake©icrrnp.org if applicable Airport Description Elevation I.(y Z31 ft, Longest runway is[Grp j ft, Number of aircraft based at airport: Airline [ General Aviation[z17I> l'lilitary L. i Runway Construction: Concrete - Turf ; Blacktop) Other(describe) f] I `�_[ Are runways lighted? A (check if yes) Air traffic is controlled' - i (check if yes) by FAA I by Non Federal X by Unicorn operated by' L Y�s i Is there an airport manager? " (check if yes) employed by applicanN: employed by independen contractor Is the manager on premises during hours of (check if yes) Hours of operation j 1c j to j i operation? Fire station located at airport' ----1 (check if yes) If riot, one is !mites fro the air o Is airport fenced? V• (check if yes) Who maintains the airport?TC' i e f � j Does the insured own, operate, or maintain any (check if yes) If so, describe:[ J aids to navigation? 1.4PAL3r Are airport premises used for any recreational or ' (check if yes) If so, describe:I I other non-aviation activities? _ — List Airlines and Scheduled Air Taxis that serve • airport currently and next three years: Largest value aircraft using airport: Aircraft � � ifg1� I value $ Present Year Next year(est.) Following Year(est.) . of Revenue Passengers (enplaned) ....__............... ......___�; .................. c [ of Airline Aircraft (landings) I j 0 iz of General Aviation Aircraft (landings) 41 D, t;,t, i4®r vat y a-b4 �1 � of Military Aircraft(landings) Cr 0 —Ji • • Loss History and previous aviation insurance Has applicant had any airport/aviation losses/claims during the last five years' (check If yes) Has any insurer cancelled,declined or refused to renew any airportiaviation insurance? (Check if yes? If"Yes"to any of the above,please explain: riarne of last or present airport/aviation insurance company: 1,4C,E ar-wer;,a 1 d Casa:r,,:r.su:aeice rcm np Policy Limits your current policy liability limits Limit of liability: $20,000,000 ;this amount is managed by ICR'•lP) Authorized Signature digital signature as an authorized executive on behalf of the applicant _.-. . Enter your name: :::/i4c-o-fii4kiii—_