ACORD 330 (2014/12) - Aircraft Section

ACORD 330 (2014/12) - Aircraft Section
ACORD 330, Aircraft Section, is used in conjunction with ACORD 325, Aviation Insurance Application - Applicant Information Section, to describe
aircraft being insured. Attach ACORD 331, Pilot Experience, if applicable.
Form Page 1
Section Name
Field Name
Description
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g., agency or
brokerage).
IDENTIFICATION SECTION
Date (MM/DD/YYYY)
Enter date: The date on which the form is completed. (MM/DD/YYYY)
IDENTIFICATION SECTION
Agency
Enter text: The full name of the producer / agency.
IDENTIFICATION SECTION
Policy Number
Enter identifier: The identifier assigned by the insurer to the policy, or submission, being
referenced exactly as it appears on the policy, including prefix and suffix symbols. If required for
self-insurance, the self-insured license or contract number.
IDENTIFICATION SECTION
Effective Date
Enter date: The effective date of the policy. The date that the terms and conditions of the policy
commence. (MM/DD/YYYY)
IDENTIFICATION SECTION
Carrier
Enter text: The insurer's full legal company name(s) as found in the file copy of the policy. Use
the actual name of the company within the group to which the policy has been issued. This is
not the insurer's group name or trade name.
IDENTIFICATION SECTION
NAIC Code
Enter code: The identification code assigned to the insurer by the NAIC.
IDENTIFICATION SECTION
Named Insured
Enter text: The named insured(s) as it / they will appear on the policy declarations page.
IDENTIFICATION SECTION
Estimated Annual Premium
Enter amount: The estimated annual premium amount for the Aircraft line of business.
AIRCRAFT INFORMATION
Aircraft #
Enter identifier: The producer assigned aircraft number.
AIRCRAFT INFORMATION
Reg Number
Enter identifier: The registration number of the aircraft (a.k.a. tail number).
AIRCRAFT INFORMATION
Base Airport ID
Enter code: The Federal Aviation Administration's designator for the airport where this aircraft is
based (e.g. ORD - O'Hare International Airport).
AIRCRAFT INFORMATION
Year
Enter year: The year of the aircraft.
AIRCRAFT INFORMATION
Make
Enter text: The manufacturer of the aircraft.
AIRCRAFT INFORMATION
Model
Enter text: The model of the aircraft.
AIRCRAFT INFORMATION
Serial #
Enter identifier: The serial number of the aircraft.
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AIRCRAFT INFORMATION
Aircraft Type
Enter code: The type of aircraft. Valid codes are:
1 - Glider
2 - Balloon
3 - Blimp-Dirigible
4 - Fixed Wing Single Engine
5 - Fixed Wing Multi Engine
6 - Rotorcraft
7 - Weight Shift Control
8 - Powered Parachute
9 - Gyroplane
OT - Other
AIRCRAFT INFORMATION
Aircraft Use
Enter code: The primary use of the aircraft (i.e. AA - Air Ambulance, BT - Banner Towing, CH -
Charter, CO - Cargo Only, FC - Full Commercial, IA - Industrial Aid, PB - Pleasure and
Business, etc.).
AIRCRAFT INFORMATION
Engine Type
Enter code: The type of engine on the aircraft.
AIRCRAFT INFORMATION
Horsepower
Enter number: The horsepower of the engine used on the aircraft.
AIRCRAFT INFORMATION
Engine Hours 1
Enter number: The number of flight hours on engine 1.
AIRCRAFT INFORMATION
Engine Hours 2
Enter number: The number of flight hours on engine 2.
AIRCRAFT INFORMATION
Engine Hours 3
Enter number: The number of flight hours on engine 3.
AIRCRAFT INFORMATION
Engine Hours 4
Enter number: The number of flight hours on engine 4.
AIRCRAFT INFORMATION
Hrs. Last 12 Mos.
Enter number: The total number of hours logged for the past 12 months.
AIRCRAFT INFORMATION
Seating Cap.
Enter number: Enter the seating capacity of the aircraft.
AIRCRAFT INFORMATION
Value
Enter amount: Enter the value of the aircraft.
AIRCRAFT INFORMATION
Hangared
Check the box (if applicable): Indicates the aircraft is stored in a hangar.
AIRCRAFT INFORMATION
Moored
Check the box (if applicable): Indicates the aircraft is moored.
AIRCRAFT INFORMATION
Tied-Out
Check the box (if applicable): Indicates the aircraft is tied out.
AIRCRAFT INFORMATION
Other Storage
Check the box (if applicable): Indicates the aircraft is stored in a manner other than those listed.
AIRCRAFT INFORMATION
Describe Other Storage
Enter text: The description of the storage area used for the aircraft.
AIRCRAFT INFORMATION
Airframe Hours
Enter number: The number of hours of the airframe.
AIRCRAFT INFORMATION
Date of Last Annual
Enter date: The date of the last annual inspection.
AIRCRAFT INFORMATION
Territory
Enter text: The description of the rating territory for the aircraft.
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AIRCRAFT INFORMATION
Aircraft Hull Valuation
Agreed Amount
Check the box (if applicable): Indicates the type of value used in determining the limit of
insurance is the agreed amount.
AIRCRAFT INFORMATION
Aircraft Hull Valuation
Insured Amount
Check the box (if applicable): Indicates the type of value used in determining the limit of
insurance is the insured amount.
AIRCRAFT INFORMATION
Aircraft Hull Option
Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
AIRCRAFT INFORMATION
Aircraft Hull Option
Description
Enter text: The description of the option being requested. Examples: All Risk Ground and Flight,
Ground and Taxi, Ground Not in Flight, Ground Not in Motion, Ground Only, In Motion Excluding
Flight, Excluding in Flight, Aircraft Storage in Hangar.
AIRCRAFT INFORMATION
Aircraft Hull Option
Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
AIRCRAFT INFORMATION
Aircraft Hull Option
Description
Enter text: The description of the option being requested. Examples: All Risk Ground and Flight,
Ground and Taxi, Ground Not in Flight, Ground Not in Motion, Ground Only, In Motion Excluding
Flight, Excluding in Flight, Aircraft Storage in Hangar.
AIRCRAFT INFORMATION
Aircraft Hull Option
Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
AIRCRAFT INFORMATION
Aircraft Hull Option
Description
Enter text: The description of the option being requested. Examples: All Risk Ground and Flight,
Ground and Taxi, Ground Not in Flight, Ground Not in Motion, Ground Only, In Motion Excluding
Flight, Excluding in Flight, Aircraft Storage in Hangar.
AIRCRAFT INFORMATION
Aircraft Hull Option
Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
AIRCRAFT INFORMATION
Aircraft Hull Option
Description
Enter text: The description of the option being requested. Examples: All Risk Ground and Flight,
Ground and Taxi, Ground Not in Flight, Ground Not in Motion, Ground Only, In Motion Excluding
Flight, Excluding in Flight, Aircraft Storage in Hangar.
AIRCRAFT INFORMATION
Aircraft Hull Limit
Enter limit: The limit amount for aircraft hull coverage.
AIRCRAFT INFORMATION
Aircraft Hull Limit Applies
To
Enter code: The code identifying what the limit applies to. Examples: Total Aircraft, Aircraft
while on Floats, Aircraft while on Skis, Floats, Skis.
AIRCRAFT INFORMATION
Aircraft Hull Limit
Enter limit: The limit amount for aircraft hull coverage.
AIRCRAFT INFORMATION
Aircraft Hull Limit Applies
To
Enter code: The code identifying what the limit applies to. Examples: Total Aircraft, Aircraft
while on Floats, Aircraft while on Skis, Floats, Skis.
AIRCRAFT INFORMATION
Aircraft Hull Limit
Enter limit: The limit amount for aircraft hull coverage.
AIRCRAFT INFORMATION
Aircraft Hull Limit Applies
To
Enter code: The code identifying what the limit applies to. Examples: Total Aircraft, Aircraft
while on Floats, Aircraft while on Skis, Floats, Skis.
AIRCRAFT INFORMATION
Aircraft Hull Deductible
Enter deductible: The deductible amount for aircraft hull coverage.
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AIRCRAFT INFORMATION
Aircraft Hull Deductible
Applies To
Enter code: The code identifying what the deductible applies to. Examples: All Other, Collision
Deductible, Comprehensive Deductible, Each Engine, Each Claim, Each and Every Loss, Each
Item, Each Tool, Ground Equipment, In Motion, Landing Gear Collapse / Gear Up Landing,
Non-Scheduled Equipment, Not In Flight, Not In Motion, Not In Motion While Hangared, All
Other Claims, Each Aircraft, Property Damage Deductible, Each Occurrence, Rotors In Motion,
Rotors Not In Motion, Scheduled Equipment.
AIRCRAFT INFORMATION
Aircraft Hull Deductible
Enter deductible: The deductible amount for aircraft hull coverage.
AIRCRAFT INFORMATION
Aircraft Hull Deductible
Applies To
Enter code: The code identifying what the deductible applies to. Examples: All Other, Collision
Deductible, Comprehensive Deductible, Each Engine, Each Claim, Each and Every Loss, Each
Item, Each Tool, Ground Equipment, In Motion, Landing Gear Collapse / Gear Up Landing,
Non-Scheduled Equipment, Not In Flight, Not In Motion, Not In Motion While Hangared, All
Other Claims, Each Aircraft, Property Damage Deductible, Each Occurrence, Rotors In Motion,
Rotors Not In Motion, Scheduled Equipment.
AIRCRAFT INFORMATION
Aircraft Hull Deductible
Enter deductible: The deductible amount for aircraft hull coverage.
AIRCRAFT INFORMATION
Aircraft Hull Deductible
Applies To
Enter code: The code identifying what the deductible applies to. Examples: All Other, Collision
Deductible, Comprehensive Deductible, Each Engine, Each Claim, Each and Every Loss, Each
Item, Each Tool, Ground Equipment, In Motion, Landing Gear Collapse / Gear Up Landing,
Non-Scheduled Equipment, Not In Flight, Not In Motion, Not In Motion While Hangared, All
Other Claims, Each Aircraft, Property Damage Deductible, Each Occurrence, Rotors In Motion,
Rotors Not In Motion, Scheduled Equipment.
AIRCRAFT INFORMATION
Aircraft Hull Premium
Enter amount: The premium amount for aircraft hull coverage.
AIRCRAFT INFORMATION
Aircraft Liability Option
Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
AIRCRAFT INFORMATION
Aircraft Liability Option
Description
Enter text: The description of the option being requested. Examples: Adjacent Fields/CBT, BI
Only, Chemical BI, Chemical BI and PD, Chemical PD, CSL BI and PD, CSL BI and PD
Excluding Passengers, CSL BI and PD Including Passengers, Excluding Chemicals, PD Only,
Total Limit.
AIRCRAFT INFORMATION
Aircraft Liability Option
Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
AIRCRAFT INFORMATION
Aircraft Liability Option
Description
Enter text: The description of the option being requested. Examples: Adjacent Fields/CBT, BI
Only, Chemical BI, Chemical BI and PD, Chemical PD, CSL BI and PD, CSL BI and PD
Excluding Passengers, CSL BI and PD Including Passengers, Excluding Chemicals, PD Only,
Total Limit.
AIRCRAFT INFORMATION
Aircraft Liability Option
Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
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AIRCRAFT INFORMATION
Aircraft Liability Option
Description
Enter text: The description of the option being requested. Examples: Adjacent Fields/CBT, BI
Only, Chemical BI, Chemical BI and PD, Chemical PD, CSL BI and PD, CSL BI and PD
Excluding Passengers, CSL BI and PD Including Passengers, Excluding Chemicals, PD Only,
Total Limit.
AIRCRAFT INFORMATION
Aircraft Liability Option
Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
AIRCRAFT INFORMATION
Aircraft Liability Option
Description
Enter text: The description of the option being requested. Examples: Adjacent Fields/CBT, BI
Only, Chemical BI, Chemical BI and PD, Chemical PD, CSL BI and PD, CSL BI and PD
Excluding Passengers, CSL BI and PD Including Passengers, Excluding Chemicals, PD Only,
Total Limit.
AIRCRAFT INFORMATION
Aircraft Liability Each
Occurrence
Enter limit: The each occurrence limit amount for aircraft liability coverage.
AIRCRAFT INFORMATION
Aircraft Liability Each
Passenger
Enter limit: The each passenger limit amount for aircraft liability coverage.
AIRCRAFT INFORMATION
Aircraft Liability Each
Person
Enter limit: The each person limit amount for aircraft liability coverage.
AIRCRAFT INFORMATION
Aircraft Liability Aggregate
Enter limit: The aggregate limit amount for aircraft liability coverage.
AIRCRAFT INFORMATION
Aircraft Liability Deductible
Enter deductible: The deductible amount for aircraft liability coverage.
AIRCRAFT INFORMATION
Aircraft Liability Deductible
Applies To
Enter code: The code identifying what the deductible applies to. Examples: All Other, Collision
Deductible, Comprehensive Deductible, Each Engine, Each Claim, Each and Every Loss, Each
Item, Each Tool, Ground Equipment, In Motion, Landing Gear Collapse / Gear Up Landing,
Non-Scheduled Equipment, Not In Flight, Not In Motion, Not In Motion While Hangared, All
Other Claims, Each Aircraft, Property Damage Deductible, Each Occurrence, Rotors In Motion,
Rotors Not In Motion, Scheduled Equipment.
AIRCRAFT INFORMATION
Aircraft Liability Deductible
Enter deductible: The deductible amount for aircraft liability coverage.
AIRCRAFT INFORMATION
Aircraft Liability Deductible
Applies To
Enter code: The code identifying what the deductible applies to. Examples: All Other, Collision
Deductible, Comprehensive Deductible, Each Engine, Each Claim, Each and Every Loss, Each
Item, Each Tool, Ground Equipment, In Motion, Landing Gear Collapse / Gear Up Landing,
Non-Scheduled Equipment, Not In Flight, Not In Motion, Not In Motion While Hangared, All
Other Claims, Each Aircraft, Property Damage Deductible, Each Occurrence, Rotors In Motion,
Rotors Not In Motion, Scheduled Equipment.
AIRCRAFT INFORMATION
Aircraft Liability Premium
Enter amount: The premium amount for aircraft liability coverage.
AIRCRAFT INFORMATION
Medical Payments Including
Crew
Check the box (if applicable): Indicates the crew is included in the medical payments coverage.
AIRCRAFT INFORMATION
Medical Payments
Excluding Crew
Check the box (if applicable): Indicates the crew is excluded from the medical payments
coverage.
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AIRCRAFT INFORMATION
Medical Payments Each
Person
Enter limit: The each person limit amount for medical payments coverage.
AIRCRAFT INFORMATION
Medical Payments Premium
Enter amount: The premium amount for medical payments coverage.
AIRCRAFT INFORMATION
Coverage Code
Enter code: The code for the coverage.
AIRCRAFT INFORMATION
Coverage Description
Enter text: The description of other coverage (not the limit) on the policy. Any questions about
appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s)
AIRCRAFT INFORMATION
Option Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
AIRCRAFT INFORMATION
Option Description
Enter text: The description of the option being requested.
AIRCRAFT INFORMATION
Option Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
AIRCRAFT INFORMATION
Option Description
Enter text: The description of the option being requested.
AIRCRAFT INFORMATION
Option Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
AIRCRAFT INFORMATION
Option Description
Enter text: The description of the option being requested.
AIRCRAFT INFORMATION
Limit
Enter limit: The limit amount for the coverage.
AIRCRAFT INFORMATION
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
AIRCRAFT INFORMATION
Limit
Enter limit: The limit amount for the coverage.
AIRCRAFT INFORMATION
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
AIRCRAFT INFORMATION
Limit
Enter limit: The limit amount for the coverage.
AIRCRAFT INFORMATION
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
AIRCRAFT INFORMATION
Deductible
Enter deductible: The deductible amount for the coverage.
AIRCRAFT INFORMATION
Applies To
Enter code: The code identifying what the deductible applies to.
AIRCRAFT INFORMATION
Deductible
Enter deductible: The deductible amount for the coverage.
AIRCRAFT INFORMATION
Applies To
Enter code: The code identifying what the deductible applies to.
AIRCRAFT INFORMATION
Deductible
Enter deductible: The deductible amount for the coverage.
AIRCRAFT INFORMATION
Applies To
Enter code: The code identifying what the deductible applies to.
AIRCRAFT INFORMATION
Premium
Enter amount: The premium amount for the coverage.
AIRCRAFT INFORMATION
Coverage Code
Enter code: The code for the coverage.
AIRCRAFT INFORMATION
Coverage Description
Enter text: The description of other coverage (not the limit) on the policy. Any questions about
appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s)
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AIRCRAFT INFORMATION
Option Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
AIRCRAFT INFORMATION
Option Description
Enter text: The description of the option being requested.
AIRCRAFT INFORMATION
Option Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
AIRCRAFT INFORMATION
Option Description
Enter text: The description of the option being requested.
AIRCRAFT INFORMATION
Option Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
AIRCRAFT INFORMATION
Option Description
Enter text: The description of the option being requested.
AIRCRAFT INFORMATION
Limit
Enter limit: The limit amount for the coverage.
AIRCRAFT INFORMATION
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
AIRCRAFT INFORMATION
Limit
Enter limit: The limit amount for the coverage.
AIRCRAFT INFORMATION
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
AIRCRAFT INFORMATION
Limit
Enter limit: The limit amount for the coverage.
AIRCRAFT INFORMATION
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
AIRCRAFT INFORMATION
Deductible
Enter deductible: The deductible amount for the coverage.
AIRCRAFT INFORMATION
Applies To
Enter code: The code identifying what the deductible applies to.
AIRCRAFT INFORMATION
Deductible
Enter deductible: The deductible amount for the coverage.
AIRCRAFT INFORMATION
Applies To
Enter code: The code identifying what the deductible applies to.
AIRCRAFT INFORMATION
Deductible
Enter deductible: The deductible amount for the coverage.
AIRCRAFT INFORMATION
Applies To
Enter code: The code identifying what the deductible applies to.
AIRCRAFT INFORMATION
Premium
Enter amount: The premium amount for the coverage.
AIRCRAFT INFORMATION
Coverage Code
Enter code: The code for the coverage.
AIRCRAFT INFORMATION
Coverage Description
Enter text: The description of other coverage (not the limit) on the policy. Any questions about
appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s)
AIRCRAFT INFORMATION
Option Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
AIRCRAFT INFORMATION
Option Description
Enter text: The description of the option being requested.
AIRCRAFT INFORMATION
Option Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
AIRCRAFT INFORMATION
Option Description
Enter text: The description of the option being requested.
AIRCRAFT INFORMATION
Option Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
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AIRCRAFT INFORMATION
Option Description
Enter text: The description of the option being requested.
AIRCRAFT INFORMATION
Limit
Enter limit: The limit amount for the coverage.
AIRCRAFT INFORMATION
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
AIRCRAFT INFORMATION
Limit
Enter limit: The limit amount for the coverage.
AIRCRAFT INFORMATION
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
AIRCRAFT INFORMATION
Limit
Enter limit: The limit amount for the coverage.
AIRCRAFT INFORMATION
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
AIRCRAFT INFORMATION
Deductible
Enter deductible: The deductible amount for the coverage.
AIRCRAFT INFORMATION
Applies To
Enter code: The code identifying what the deductible applies to.
AIRCRAFT INFORMATION
Deductible
Enter deductible: The deductible amount for the coverage.
AIRCRAFT INFORMATION
Applies To
Enter code: The code identifying what the deductible applies to.
AIRCRAFT INFORMATION
Deductible
Enter deductible: The deductible amount for the coverage.
AIRCRAFT INFORMATION
Applies To
Enter code: The code identifying what the deductible applies to.
AIRCRAFT INFORMATION
Premium
Enter amount: The premium amount for the coverage.
AIRCRAFT INFORMATION
Coverage Code
Enter code: The code for the coverage.
AIRCRAFT INFORMATION
Coverage Description
Enter text: The description of other coverage (not the limit) on the policy. Any questions about
appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s)
AIRCRAFT INFORMATION
Option Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
AIRCRAFT INFORMATION
Option Description
Enter text: The description of the option being requested.
AIRCRAFT INFORMATION
Option Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
AIRCRAFT INFORMATION
Option Description
Enter text: The description of the option being requested.
AIRCRAFT INFORMATION
Option Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
AIRCRAFT INFORMATION
Option Description
Enter text: The description of the option being requested.
AIRCRAFT INFORMATION
Limit
Enter limit: The limit amount for the coverage.
AIRCRAFT INFORMATION
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
AIRCRAFT INFORMATION
Limit
Enter limit: The limit amount for the coverage.
AIRCRAFT INFORMATION
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
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AIRCRAFT INFORMATION
Limit
Enter limit: The limit amount for the coverage.
AIRCRAFT INFORMATION
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
AIRCRAFT INFORMATION
Deductible
Enter deductible: The deductible amount for the coverage.
AIRCRAFT INFORMATION
Applies To
Enter code: The code identifying what the deductible applies to.
AIRCRAFT INFORMATION
Deductible
Enter deductible: The deductible amount for the coverage.
AIRCRAFT INFORMATION
Applies To
Enter code: The code identifying what the deductible applies to.
AIRCRAFT INFORMATION
Deductible
Enter deductible: The deductible amount for the coverage.
AIRCRAFT INFORMATION
Applies To
Enter code: The code identifying what the deductible applies to.
AIRCRAFT INFORMATION
Premium
Enter amount: The premium amount for the coverage.
OPEN PILOT WARRANTY
Form Number
Enter identifier: The number used by the insurer for this form.
OPEN PILOT WARRANTY
Form Name
Enter text: The name of the form.
OPEN PILOT WARRANTY
Description
Enter text: The description of the form.
OPEN PILOT WARRANTY
Form Number
Enter identifier: The number used by the insurer for this form.
OPEN PILOT WARRANTY
Form Name
Enter text: The name of the form.
OPEN PILOT WARRANTY
Description
Enter text: The description of the form.
BASE AIRPORT
INFORMATION
Loc #
Enter number: The producer assigned number of the location.
BASE AIRPORT
INFORMATION
Airport ID
Enter identifier: The Federal Aviation Administration's designator for the airport (e.g. ORD -
O'Hare International Airport).
BASE AIRPORT
INFORMATION
Airport Name, City, State
Enter text: The full name of the location.
BASE AIRPORT
INFORMATION
Enter text: The city of the physical location.
BASE AIRPORT
INFORMATION
Enter code: The state or province of the physical location.
BASE AIRPORT
INFORMATION
Private
Check the box (if applicable): Indicates the airport is a private airport.
BASE AIRPORT
INFORMATION
Public
Check the box (if applicable): Indicates the airport is a public airport.
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BASE AIRPORT
INFORMATION
Restricted
Check the box (if applicable): Indicates the airport is a restricted airport.
BASE AIRPORT
INFORMATION
Other Airport Type
Check the box (if applicable): Indicates the airport type is other than those listed.
BASE AIRPORT
INFORMATION
Describe Other Airport Type
Enter text: The description of the type of airport.
BASE AIRPORT
INFORMATION
Hangared
Check the box (if applicable): Indicates the hangars are available for aircraft storage.
BASE AIRPORT
INFORMATION
Moored
Check the box (if applicable): Indicates aircraft are moored at the airport.
BASE AIRPORT
INFORMATION
Tied-Out
Check the box (if applicable): Indicates aircraft are tied out at the airport.
BASE AIRPORT
INFORMATION
Other Storage
Check the box (if applicable): Indicates the airport has aircraft storage facilities other than those
listed.
BASE AIRPORT
INFORMATION
Describe Other Storage
Enter text: The description of the aircraft storage facilities available at the airport.
BASE AIRPORT
INFORMATION
Length of Longest Runway
Enter number: The length of the longest runway in feet.
BASE AIRPORT
INFORMATION
Width of Longest Runway
Enter number: The width of the longest runway in feet.
BASE AIRPORT
INFORMATION
Are runways paved?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Are the runways paved?.
BASE AIRPORT
INFORMATION
If runways are not paved,
explain.
Enter text: An explanation as to whether runways are not paved.
BASE AIRPORT
INFORMATION
Are runways lighted?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Are runways lighted?.
Form Page 2
Section Name
Field Name
Description
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g., agency or
brokerage).
CORPORATE NON-OWNED
COMPANY APPLICANTS
Flying Hours Last Year:
Enter year: The year for the flying hours you are reporting for last year.
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CORPORATE NON-OWNED
COMPANY APPLICANTS
Flying Hours Next Year:
Enter year: The year for the flying hours you are reporting for next year.
CORPORATE NON-OWNED
COMPANY APPLICANTS
Annual Last Year
Enter number: The total annual flying hours for last year.
CORPORATE NON-OWNED
COMPANY APPLICANTS
Annual Next Year
Enter number: The estimated total annual flying hours for next year.
CORPORATE NON-OWNED
COMPANY APPLICANTS
Rented and use of employee
owner aircraft. Last Year
Enter number: The number of flying hours for rented and use of employee owner aircraft for last
year.
CORPORATE NON-OWNED
COMPANY APPLICANTS
Rented and use of employee
owner aircraft. Next Year
Enter number: The estimated number of flying hours for rented and use of employee owner
aircraft for next year.
CORPORATE NON-OWNED
COMPANY APPLICANTS
Chartered aircraft with
non-employee pilots Last
Year
Enter number: The number of flying hours for chartered aircraft with non-employee pilots for last
year.
CORPORATE NON-OWNED
COMPANY APPLICANTS
Chartered aircraft with
non-employee pilots Next
Year
Enter number: The estimated number of flying hours for chartered aircraft with non-employee
pilots for next year.
CORPORATE NON-OWNED
COMPANY APPLICANTS
Employees
Check the box (if applicable): Indicates employees are passengers on the non-owned aircraft.
CORPORATE NON-OWNED
COMPANY APPLICANTS
Family Members
Check the box (if applicable): Indicates family members are passengers on the non-owned
aircraft.
CORPORATE NON-OWNED
COMPANY APPLICANTS
Guests
Check the box (if applicable): Indicates guests are passengers on the non-owned aircraft.
CORPORATE NON-OWNED
COMPANY APPLICANTS
Average Number of
Passengers Each Trip
Enter number: The average number of passengers on each trip.
CORPORATE NON-OWNED
COMPANY APPLICANTS
Branch Offices
Enter number: The number of branch offices.
CORPORATE NON-OWNED
COMPANY APPLICANTS
Total Employees
Enter number: The number of total employees.
CORPORATE NON-OWNED
COMPANY APPLICANTS
Employees who are pilots
Enter number: The number of employees who are pilots.
CORPORATE NON-OWNED
COMPANY APPLICANTS
Employees employed in a
pilot capacity.
Enter number: The number of employees employed in a pilot capacity.
CORPORATE NON-OWNED
COMPANY APPLICANTS
Employees owning aircraft.
Enter number: The number of employees owning aircraft.
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CORPORATE NON-OWNED
COMPANY APPLICANTS
Employees whose regular
duties include aircraft travel.
Enter number: The number of employees whose regular duties include aircraft travel.
CORPORATE NON-OWNED
COMPANY APPLICANTS
Employees owning aircraft
used on company business
Enter number: The number of employees owning aircraft use on company business
CORPORATE NON-OWNED
COMPANY APPLICANTS
Liability Limit carried on
primary basis
Enter limit: The liability limit carried on a primary basis for employees owning aircraft used on
company business.
CORPORATE NON-OWNED
COMPANY APPLICANTS
Is insured listed as an
additional insured?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
If an employee flies their own aircraft on company business, is the applicant listed as an
additional insured on the employees' policy?.
CORPORATE NON-OWNED
COMPANY APPLICANTS
Aircraft Owned by Company
Enter number: The number of aircraft owned by the company.
CORPORATE NON-OWNED
COMPANY APPLICANTS
Make
Enter text: The name of the manufacturer of the aircraft.
CORPORATE NON-OWNED
COMPANY APPLICANTS
Model
Enter text: The model name of the aircraft.
CORPORATE NON-OWNED
COMPANY APPLICANTS
1. Any charters or rentals for
more than seven
consecutive days?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Any charters or rentals for more than seven consecutive days?.
CORPORATE NON-OWNED
COMPANY APPLICANTS
Explain
Enter text: An explanation as to whether there are any charters or rentals for more than seven
(7) consecutive days.
CORPORATE NON-OWNED
COMPANY APPLICANTS
2. Any use of jets,
helicopters, or aircraft over
eight-place including crew?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Any use of jets, helicopters or aircraft over eight-place including crew?.
CORPORATE NON-OWNED
COMPANY APPLICANTS
Explain
Enter text: An explanation as to whether there is any use of jets, helicopters or aircraft over
eight-place including the crew.
CORPORATE NON-OWNED
COMPANY APPLICANTS
3. Is the insured, as a
customer, included as an
additional insured on the
charter primary policy?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Is insured, as a customer, included as an additional insured on the charter primary policy?.
CORPORATE NON-OWNED
COMPANY APPLICANTS
a) If yes, has a certificate of
insurance been obtained?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
If insured, as a customer, is included as an additional insured on the charter primary policy, has
a certificate of insurance been obtained?.
CORPORATE NON-OWNED
COMPANY APPLICANTS
4. Liability limit on rented or
chartered aircraft:
Enter limit: The liability limit on rented or chartered aircraft.
TURBINE AIRCRAFT
Flying Hours Last Year:
Enter year: The year for the flying hours you are reporting for last year.
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TURBINE AIRCRAFT
Flying Hours Next Year:
Enter year: The year for the flying hours you are reporting for next year.
TURBINE AIRCRAFT
Annual Last Year
Enter number: The total annual flying hours for last year.
TURBINE AIRCRAFT
Annual Next Year
Enter number: The estimated total annual flying hours for next year.
TURBINE AIRCRAFT
Rented and use of employee
owner aircraft. Last Year
Enter number: The number of flying hours for rented and use of employee owner aircraft for last
year.
TURBINE AIRCRAFT
Rented and use of employee
owner aircraft. Next Year
Enter number: The estimated number of flying hours for rented and use of employee owner
aircraft for next year.
TURBINE AIRCRAFT
Chartered aircraft with
non-employee pilots Last
Year
Enter number: The number of flying hours for chartered aircraft with non-employee pilots for last
year.
TURBINE AIRCRAFT
Chartered aircraft with
non-employee pilots Next
Year
Enter number: The estimated number of flying hours for chartered aircraft with non-employee
pilots for next year.
TURBINE AIRCRAFT
Employees
Check the box (if applicable): Indicates employees are passengers on the non-owned aircraft.
TURBINE AIRCRAFT
Family Members
Check the box (if applicable): Indicates family members are passengers on the non-owned
aircraft.
TURBINE AIRCRAFT
Guests
Check the box (if applicable): Indicates guests are passengers on the non-owned aircraft.
TURBINE AIRCRAFT
Average Number of
Passengers Each Trip
Enter number: The average number of passengers on each trip.
TURBINE AIRCRAFT
Maintenance Facility
Enter text: The maintenance facility used for the aircraft.
TURBINE AIRCRAFT
Maintenance Program
Enter text: The maintenance program used on the aircraft.
TURBINE AIRCRAFT
Is the aircraft equipped with
a traffic and/or terrain
collision avoidance system?
If yes, enter type:
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Is the aircraft equipped with a traffic and/or terrain collision avoidance system?. As used here,
if yes, enter type of traffic and / or terrain collision avoidance system.
TURBINE AIRCRAFT
Explain
Enter text: The type of traffic and/or terrain collision avoidance system.
AGRICULTURAL AIRCRAFT
Enter names used in any
former aerial application
business.
Enter text: The name used in any former aerial application business.
AGRICULTURAL AIRCRAFT
Enter names used in any
former aerial application
business.
Enter text: The name used in any former aerial application business.
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AGRICULTURAL AIRCRAFT
Enter names used in any
former aerial application
business.
Enter text: The name used in any former aerial application business.
AGRICULTURAL AIRCRAFT
Enter names used in any
former aerial application
business.
Enter text: The name used in any former aerial application business.
AGRICULTURAL AIRCRAFT
Num Years Conducting
Aerial Agricultural
Operations
Enter number: The number of years the insured has been conducting aerial agricultural
operations.
AGRICULTURAL AIRCRAFT
Home State of Operation
Enter code: The state or province code for the home state of operations.
AGRICULTURAL AIRCRAFT
Describe Operations in
Other States
Enter text: The description of operations conducted in other states.
AGRICULTURAL AIRCRAFT
If you participate in NAAA
PAASS safety program,
enter last date completed
Enter date: The date the safety program was completed. This is date the National Agricultural
Aviation Association (NAAA) Professional Aerial Application Support System (PAASS) Safety
Program was completed.
AGRICULTURAL AIRCRAFT
Number of Aircraft owned,
leased or operated by you
Enter number: The number of aircraft owned, leased or operated by the insured.
AGRICULTURAL AIRCRAFT
1. Do you spray: Picloram
Formulations (i.e. Tordon,
Grazon, etc.)
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Do you spray - Picloram formulations (i.e. Tordon, Grazon, etc.)?.
AGRICULTURAL AIRCRAFT
Explain
Enter text: An explanation as to whether you spray picloram formations (i.e., Tordon, Grazon,
etc.)
AGRICULTURAL AIRCRAFT
2. Do you sell, distribute, or
provide any chemicals?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Do you sell, distribute, or provide any chemicals?.
AGRICULTURAL AIRCRAFT
Explain
Enter text: An explanation as to whether you sell, distribute or provide any chemicals.
AGRICULTURAL AIRCRAFT
3. Are you a member of your
state agricultural aviation
association?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Are you a member of your State Agricultural Aviation Association?.
AGRICULTURAL AIRCRAFT
4. Are you a member of any
other state agricultural
aviation association?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Are you a member of any other State Agricultural Aviation Association?.
AGRICULTURAL AIRCRAFT
Explain
Enter text: An explanation as to whether you are a member of any other state agricultural
aviation association.
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AGRICULTURAL AIRCRAFT
5. Are you a member of the
National Agricultural
Aviation Association?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Are you a member of the National Agricultural Aviation Association?.
AGRICULTURAL AIRCRAFT
6. Have you had any
workers compensation
claims?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Have you had any Workers Compensation claims?.
AGRICULTURAL AIRCRAFT
Date of Loss
Enter date: The date that the loss occurred.
AGRICULTURAL AIRCRAFT
Explain
Enter text: An explanation as to whether you have had any workers' compensation claims.
AGRICULTURAL AIRCRAFT
7. Have any of your pilots
been cited or fined?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Have any of your pilots been cited or fined?.
AGRICULTURAL AIRCRAFT
Explain
Enter text: An explanation as to whether any of your pilots have been cited or fined.
AGRICULTURAL AIRCRAFT
8. Do you spray over any
residential (or populated)
areas?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Do you spray over any residential (or populated) areas?.
AGRICULTURAL AIRCRAFT
Explain
Enter text: An explanation as to whether you spray over any residential or populated areas.
AGRICULTURAL AIRCRAFT
9. Do you spray
right-of-ways?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Do you spray right-of-ways?.
AGRICULTURAL AIRCRAFT
Explain
Enter text: An explanation as to whether you spray right-of-ways.
AGRICULTURAL AIRCRAFT
Describe additional uses.
Enter text: The description of additional uses for the aircraft.
Form Page 3
Section Name
Field Name
Description
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g., agency or
brokerage).
ADDITIONAL INTERESTS
Additional Insured
Check the box (if applicable): Indicates the additional interest type is an additional insured.
ADDITIONAL INTERESTS
Breach of Warranty
Check the box (if applicable): Indicates the additional interest type is a breach of warranty.
ADDITIONAL INTERESTS
Co-Owner
Check the box (if applicable): Indicates the additional interest type is a co-owner.
ADDITIONAL INTERESTS
Leaseback Owner
Check the box (if applicable): Indicates the additional interest type is a leaseback owner.
ADDITIONAL INTERESTS
Lienholder
Check the box (if applicable): Indicates the additional interest type is a lien holder.
ADDITIONAL INTERESTS
Loss Payee
Check the box (if applicable): Indicates the additional interest type is a loss payee.
ADDITIONAL INTERESTS
Mortgagee
Check the box (if applicable): Indicates the additional interest type is a mortgagee.
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ADDITIONAL INTERESTS
Other Additional Interest
Check the box (if applicable): Indicates the additional interest is other than those listed.
ADDITIONAL INTERESTS
Describe Other Additional
Interest
Enter text: The description of the other type of additional interest.
ADDITIONAL INTERESTS
Rank
Enter number: The ranking of 'this' additional interest when multiple additional interests are
associated with the same item.
ADDITIONAL INTERESTS
Evidence: Certificate
Check the box (if applicable): Indicates if the additional interest requires a Certificate of
Insurance.
ADDITIONAL INTERESTS
Name and address
Enter text: The additional interest's full name.
ADDITIONAL INTERESTS
Enter text: The additional interest's mailing address line one.
ADDITIONAL INTERESTS
Enter text: The additional interest's mailing address line two.
ADDITIONAL INTERESTS
Enter text: The additional interest's mailing address city name.
ADDITIONAL INTERESTS
Enter code: The additional interest's mailing address state or province code.
ADDITIONAL INTERESTS
Enter code: The additional interest's mailing address postal code.
ADDITIONAL INTERESTS
Enter code: The additional interest's country code.
ADDITIONAL INTERESTS
Phone
Enter number: The primary phone number of the additional interest.
ADDITIONAL INTERESTS
Fax
Enter number: The primary fax number of the additional interest.
ADDITIONAL INTERESTS
E-mail Address
Enter text: The primary e-mail address for the additional interest.
ADDITIONAL INTERESTS
Reference # / Loan #
Enter identifier: The loan number, account number or other controlling number that the
additional interest may have assigned the insured.
ADDITIONAL INTERESTS
Lien Amount
Enter amount: The amount of the loan.
ADDITIONAL INTERESTS
Interest End Date
Enter date: The date the interest holder's interest terminates.
ADDITIONAL INTERESTS
Location
Enter number: The producer assigned number of the location which has an additional interest.
ADDITIONAL INTERESTS
Building
Enter number: The producer assigned number of the building which has an additional interest.
ADDITIONAL INTERESTS
Airport
Enter identifier: The Federal Aviation Administration's designator for the airport (e.g. ORD -
O'Hare International Airport).
ADDITIONAL INTERESTS
Aircraft
Enter number: The producer assigned number of the aircraft which has an additional interest.
ADDITIONAL INTERESTS
Item Class
Enter code: The description of the property class of the scheduled item (i.e. Jewelry, Furs,
Contractors Equipment, etc.).
ADDITIONAL INTERESTS
Item
Enter number: The producer assigned number of the scheduled item which has an additional
interest.
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Page 16 of 27
ADDITIONAL INTERESTS
Item Description
Enter text: The description of the item which has an additional interest.
ADDITIONAL INTERESTS
Reason for Interest
Enter text: The description for the interest in the item.
POLICY COVERAGES
Aircraft Hull Valuation
Agreed Amount
Check the box (if applicable): Indicates the type of value used in determining the limit of
insurance is the agreed amount.
POLICY COVERAGES
Aircraft Hull Valuation
Insured Amount
Check the box (if applicable): Indicates the type of value used in determining the limit of
insurance is the insured amount.
POLICY COVERAGES
Aircraft Hull Option
Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
POLICY COVERAGES
Aircraft Hull Option
Description
Enter text: The description of the option being requested. Examples: All Risk Ground and Flight,
Ground and Taxi, Ground Not in Flight, Ground Not in Motion, Ground Only, In Motion Excluding
Flight, Excluding in Flight, Aircraft Storage in Hangar.
POLICY COVERAGES
Aircraft Hull Option
Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
POLICY COVERAGES
Aircraft Hull Option
Description
Enter text: The description of the option being requested. Examples: All Risk Ground and Flight,
Ground and Taxi, Ground Not in Flight, Ground Not in Motion, Ground Only, In Motion Excluding
Flight, Excluding in Flight, Aircraft Storage in Hangar.
POLICY COVERAGES
Aircraft Hull Option
Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
POLICY COVERAGES
Aircraft Hull Option
Description
Enter text: The description of the option being requested. Examples: All Risk Ground and Flight,
Ground and Taxi, Ground Not in Flight, Ground Not in Motion, Ground Only, In Motion Excluding
Flight, Excluding in Flight, Aircraft Storage in Hangar.
POLICY COVERAGES
Aircraft Hull Option
Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
POLICY COVERAGES
Aircraft Hull Option
Description
Enter text: The description of the option being requested. Examples: All Risk Ground and Flight,
Ground and Taxi, Ground Not in Flight, Ground Not in Motion, Ground Only, In Motion Excluding
Flight, Excluding in Flight, Aircraft Storage in Hangar.
POLICY COVERAGES
Aircraft Hull Limit
Enter limit: The limit amount for aircraft hull coverage.
POLICY COVERAGES
Aircraft Hull Limit Applies
To
Enter code: The code identifying what the limit applies to. Examples: Total Aircraft, Aircraft
while on Floats, Aircraft while on Skis, Floats, Skis.
POLICY COVERAGES
Aircraft Hull Limit
Enter limit: The limit amount for aircraft hull coverage.
POLICY COVERAGES
Aircraft Hull Limit Applies
To
Enter code: The code identifying what the limit applies to. Examples: Total Aircraft, Aircraft
while on Floats, Aircraft while on Skis, Floats, Skis.
POLICY COVERAGES
Aircraft Hull Limit
Enter limit: The limit amount for aircraft hull coverage.
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POLICY COVERAGES
Aircraft Hull Limit Applies
To
Enter code: The code identifying what the limit applies to. Examples: Total Aircraft, Aircraft
while on Floats, Aircraft while on Skis, Floats, Skis.
POLICY COVERAGES
Aircraft Hull Deductible
Enter deductible: The deductible amount for aircraft hull coverage.
POLICY COVERAGES
Aircraft Hull Deductible
Applies To
Enter code: The code identifying what the deductible applies to. Examples: All Other, Collision
Deductible, Comprehensive Deductible, Each Engine, Each Claim, Each and Every Loss, Each
Item, Each Tool, Ground Equipment, In Motion, Landing Gear Collapse / Gear Up Landing,
Non-Scheduled Equipment, Not In Flight, Not In Motion, Not In Motion While Hangared, All
Other Claims, Each Aircraft, Property Damage Deductible, Each Occurrence, Rotors In Motion,
Rotors Not In Motion, Scheduled Equipment.
POLICY COVERAGES
Aircraft Hull Deductible
Enter deductible: The deductible amount for aircraft hull coverage.
POLICY COVERAGES
Aircraft Hull Deductible
Applies To
Enter code: The code identifying what the deductible applies to. Examples: All Other, Collision
Deductible, Comprehensive Deductible, Each Engine, Each Claim, Each and Every Loss, Each
Item, Each Tool, Ground Equipment, In Motion, Landing Gear Collapse / Gear Up Landing,
Non-Scheduled Equipment, Not In Flight, Not In Motion, Not In Motion While Hangared, All
Other Claims, Each Aircraft, Property Damage Deductible, Each Occurrence, Rotors In Motion,
Rotors Not In Motion, Scheduled Equipment.
POLICY COVERAGES
Aircraft Hull Deductible
Enter deductible: The deductible amount for aircraft hull coverage.
POLICY COVERAGES
Aircraft Hull Deductible
Applies To
Enter code: The code identifying what the deductible applies to. Examples: All Other, Collision
Deductible, Comprehensive Deductible, Each Engine, Each Claim, Each and Every Loss, Each
Item, Each Tool, Ground Equipment, In Motion, Landing Gear Collapse / Gear Up Landing,
Non-Scheduled Equipment, Not In Flight, Not In Motion, Not In Motion While Hangared, All
Other Claims, Each Aircraft, Property Damage Deductible, Each Occurrence, Rotors In Motion,
Rotors Not In Motion, Scheduled Equipment.
POLICY COVERAGES
Aircraft Hull Premium
Enter amount: The premium amount for aircraft hull coverage.
POLICY COVERAGES
Aircraft Liability Option
Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
POLICY COVERAGES
Aircraft Liability Option
Description
Enter text: The description of the option being requested. Examples: Adjacent Fields/CBT, BI
Only, Chemical BI, Chemical BI and PD, Chemical PD, CSL BI and PD, CSL BI and PD
Excluding Passengers, CSL BI and PD Including Passengers, Excluding Chemicals, PD Only,
Total Limit.
POLICY COVERAGES
Aircraft Liability Option
Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
POLICY COVERAGES
Aircraft Liability Option
Description
Enter text: The description of the option being requested. Examples: Adjacent Fields/CBT, BI
Only, Chemical BI, Chemical BI and PD, Chemical PD, CSL BI and PD, CSL BI and PD
Excluding Passengers, CSL BI and PD Including Passengers, Excluding Chemicals, PD Only,
Total Limit.
ACORD 330 (2014/12) rev. 04-29-2014
Page 18 of 27
POLICY COVERAGES
Aircraft Liability Option
Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
POLICY COVERAGES
Aircraft Liability Option
Description
Enter text: The description of the option being requested. Examples: Adjacent Fields/CBT, BI
Only, Chemical BI, Chemical BI and PD, Chemical PD, CSL BI and PD, CSL BI and PD
Excluding Passengers, CSL BI and PD Including Passengers, Excluding Chemicals, PD Only,
Total Limit.
POLICY COVERAGES
Aircraft Liability Option
Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
POLICY COVERAGES
Aircraft Liability Option
Description
Enter text: The description of the option being requested. Examples: Adjacent Fields/CBT, BI
Only, Chemical BI, Chemical BI and PD, Chemical PD, CSL BI and PD, CSL BI and PD
Excluding Passengers, CSL BI and PD Including Passengers, Excluding Chemicals, PD Only,
Total Limit.
POLICY COVERAGES
Aircraft Liability Each
Occurrence
Enter limit: The each occurrence limit amount for aircraft liability coverage.
POLICY COVERAGES
Aircraft Liability Each
Passenger
Enter limit: The each passenger limit amount for aircraft liability coverage.
POLICY COVERAGES
Aircraft Liability Each
Person
Enter limit: The each person limit amount for aircraft liability coverage.
POLICY COVERAGES
Aircraft Liability Aggregate
Enter limit: The aggregate limit amount for aircraft liability coverage.
POLICY COVERAGES
Aircraft Liability Deductible
Enter deductible: The deductible amount for aircraft liability coverage.
POLICY COVERAGES
Aircraft Liability Deductible
Applies To
Enter code: The code identifying what the deductible applies to. Examples: All Other, Collision
Deductible, Comprehensive Deductible, Each Engine, Each Claim, Each and Every Loss, Each
Item, Each Tool, Ground Equipment, In Motion, Landing Gear Collapse / Gear Up Landing,
Non-Scheduled Equipment, Not In Flight, Not In Motion, Not In Motion While Hangared, All
Other Claims, Each Aircraft, Property Damage Deductible, Each Occurrence, Rotors In Motion,
Rotors Not In Motion, Scheduled Equipment.
POLICY COVERAGES
Aircraft Liability Deductible
Enter deductible: The deductible amount for aircraft liability coverage.
POLICY COVERAGES
Aircraft Liability Deductible
Applies To
Enter code: The code identifying what the deductible applies to. Examples: All Other, Collision
Deductible, Comprehensive Deductible, Each Engine, Each Claim, Each and Every Loss, Each
Item, Each Tool, Ground Equipment, In Motion, Landing Gear Collapse / Gear Up Landing,
Non-Scheduled Equipment, Not In Flight, Not In Motion, Not In Motion While Hangared, All
Other Claims, Each Aircraft, Property Damage Deductible, Each Occurrence, Rotors In Motion,
Rotors Not In Motion, Scheduled Equipment.
POLICY COVERAGES
Aircraft Liability Premium
Enter amount: The premium amount for aircraft liability coverage.
POLICY COVERAGES
Medical Payments Including
Crew
Check the box (if applicable): Indicates the crew is included in the medical payments coverage.
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Page 19 of 27
POLICY COVERAGES
Medical Payments
Excluding Crew
Check the box (if applicable): Indicates the crew is excluded from the medical payments
coverage.
POLICY COVERAGES
Medical Payments Each
Person
Enter limit: The each person limit amount for medical payments coverage.
POLICY COVERAGES
Medical Payments Premium
Enter amount: The premium amount for medical payments coverage.
POLICY COVERAGES
Builder's Risk Option
Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
POLICY COVERAGES
Builder's Risk Option
Description
Enter text: The description of the option being requested.
POLICY COVERAGES
Builder's Risk Option
Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
POLICY COVERAGES
Builder's Risk Option
Description
Enter text: The description of the option being requested.
POLICY COVERAGES
Builder's Risk Limit
Enter limit: The limit amount for builder's risk coverage.
POLICY COVERAGES
Builder's Risk Limit Applies
To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
POLICY COVERAGES
Builder's Risk Limit
Enter limit: The limit amount for builder's risk coverage.
POLICY COVERAGES
Builder's Risk Limit Applies
To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
POLICY COVERAGES
Builder's Risk Deductible
Enter deductible: The deductible amount for builder's risk coverage.
POLICY COVERAGES
Builder's Risk Deductible
Applies To
Enter code: The code identifying what the deductible applies to.
POLICY COVERAGES
Builder's Risk Deductible
Enter deductible: The deductible amount for builder's risk coverage.
POLICY COVERAGES
Builder's Risk Deductible
Applies To
Enter code: The code identifying what the deductible applies to.
POLICY COVERAGES
Builder's Risk Premium
Enter amount: The premium amount for builder's risk coverage.
POLICY COVERAGES
Coverage Code
Enter code: The code for the coverage.
POLICY COVERAGES
Coverage Description
Enter text: The description of other coverage (not the limit) on the policy. Any questions about
appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s)
POLICY COVERAGES
Options Check Box
Check the box (if applicable): Indicates a coverage option applies to the coverage.
POLICY COVERAGES
Describe Option
Enter text: The description of the option being requested.
ACORD 330 (2014/12) rev. 04-29-2014
Page 20 of 27
POLICY COVERAGES
Options Check Box
Check the box (if applicable): Indicates a coverage option applies to the coverage.
POLICY COVERAGES
Describe Option
Enter text: The description of the option being requested.
POLICY COVERAGES
Options Check Box
Check the box (if applicable): Indicates a coverage option applies to the coverage.
POLICY COVERAGES
Describe Option
Enter text: The description of the option being requested.
POLICY COVERAGES
Limit
Enter limit: The limit amount for the coverage.
POLICY COVERAGES
Limit Applies to:
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
POLICY COVERAGES
Limit
Enter limit: The limit amount for the coverage.
POLICY COVERAGES
Limit Applies to:
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
POLICY COVERAGES
Limit
Enter limit: The limit amount for the coverage.
POLICY COVERAGES
Limit Applies to:
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
POLICY COVERAGES
Deductible
Enter deductible: The deductible amount for the coverage.
POLICY COVERAGES
Deductible Applies to:
Enter code: The code identifying what the deductible applies to.
POLICY COVERAGES
Deductible
Enter deductible: The deductible amount for the coverage.
POLICY COVERAGES
Deductible Applies to:
Enter code: The code identifying what the deductible applies to.
POLICY COVERAGES
Deductible
Enter deductible: The deductible amount for the coverage.
POLICY COVERAGES
Deductible Applies to:
Enter code: The code identifying what the deductible applies to.
POLICY COVERAGES
Premium
Enter amount: The premium amount for the coverage.
POLICY COVERAGES
Coverage Code
Enter code: The code for the coverage.
POLICY COVERAGES
Coverage Description
Enter text: The description of other coverage (not the limit) on the policy. Any questions about
appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s)
POLICY COVERAGES
Options Check Box
Check the box (if applicable): Indicates a coverage option applies to the coverage.
POLICY COVERAGES
Describe Option
Enter text: The description of the option being requested.
POLICY COVERAGES
Options Check Box
Check the box (if applicable): Indicates a coverage option applies to the coverage.
POLICY COVERAGES
Describe Option
Enter text: The description of the option being requested.
POLICY COVERAGES
Options Check Box
Check the box (if applicable): Indicates a coverage option applies to the coverage.
POLICY COVERAGES
Describe Option
Enter text: The description of the option being requested.
POLICY COVERAGES
Limit
Enter limit: The limit amount for the coverage.
ACORD 330 (2014/12) rev. 04-29-2014
Page 21 of 27
POLICY COVERAGES
Limit Applies to:
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
POLICY COVERAGES
Limit
Enter limit: The limit amount for the coverage.
POLICY COVERAGES
Limit Applies to:
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
POLICY COVERAGES
Limit
Enter limit: The limit amount for the coverage.
POLICY COVERAGES
Limit Applies to:
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
POLICY COVERAGES
Deductible
Enter deductible: The deductible amount for the coverage.
POLICY COVERAGES
Deductible Applies to:
Enter code: The code identifying what the deductible applies to.
POLICY COVERAGES
Deductible
Enter deductible: The deductible amount for the coverage.
POLICY COVERAGES
Deductible Applies to:
Enter code: The code identifying what the deductible applies to.
POLICY COVERAGES
Deductible
Enter deductible: The deductible amount for the coverage.
POLICY COVERAGES
Deductible Applies to:
Enter code: The code identifying what the deductible applies to.
POLICY COVERAGES
Premium
Enter amount: The premium amount for the coverage.
POLICY COVERAGES
Coverage Code
Enter code: The code for the coverage.
POLICY COVERAGES
Coverage Description
Enter text: The description of other coverage (not the limit) on the policy. Any questions about
appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s)
POLICY COVERAGES
Options Check Box
Check the box (if applicable): Indicates a coverage option applies to the coverage.
POLICY COVERAGES
Describe Option
Enter text: The description of the option being requested.
POLICY COVERAGES
Options Check Box
Check the box (if applicable): Indicates a coverage option applies to the coverage.
POLICY COVERAGES
Describe Option
Enter text: The description of the option being requested.
POLICY COVERAGES
Options Check Box
Check the box (if applicable): Indicates a coverage option applies to the coverage.
POLICY COVERAGES
Describe Option
Enter text: The description of the option being requested.
POLICY COVERAGES
Limit
Enter limit: The limit amount for the coverage.
POLICY COVERAGES
Limit Applies to:
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
POLICY COVERAGES
Limit
Enter limit: The limit amount for the coverage.
POLICY COVERAGES
Limit Applies to:
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
POLICY COVERAGES
Limit
Enter limit: The limit amount for the coverage.
POLICY COVERAGES
Limit Applies to:
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
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Page 22 of 27
POLICY COVERAGES
Deductible
Enter deductible: The deductible amount for the coverage.
POLICY COVERAGES
Deductible Applies to:
Enter code: The code identifying what the deductible applies to.
POLICY COVERAGES
Deductible
Enter deductible: The deductible amount for the coverage.
POLICY COVERAGES
Deductible Applies to:
Enter code: The code identifying what the deductible applies to.
POLICY COVERAGES
Deductible
Enter deductible: The deductible amount for the coverage.
POLICY COVERAGES
Deductible Applies to:
Enter code: The code identifying what the deductible applies to.
POLICY COVERAGES
Premium
Enter amount: The premium amount for the coverage.
POLICY COVERAGES
Coverage Code
Enter code: The code for the coverage.
POLICY COVERAGES
Coverage Description
Enter text: The description of other coverage (not the limit) on the policy. Any questions about
appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s)
POLICY COVERAGES
Options Check Box
Check the box (if applicable): Indicates a coverage option applies to the coverage.
POLICY COVERAGES
Describe Option
Enter text: The description of the option being requested.
POLICY COVERAGES
Options Check Box
Check the box (if applicable): Indicates a coverage option applies to the coverage.
POLICY COVERAGES
Describe Option
Enter text: The description of the option being requested.
POLICY COVERAGES
Options Check Box
Check the box (if applicable): Indicates a coverage option applies to the coverage.
POLICY COVERAGES
Describe Option
Enter text: The description of the option being requested.
POLICY COVERAGES
Limit
Enter limit: The limit amount for the coverage.
POLICY COVERAGES
Limit Applies to:
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
POLICY COVERAGES
Limit
Enter limit: The limit amount for the coverage.
POLICY COVERAGES
Limit Applies to:
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
POLICY COVERAGES
Limit
Enter limit: The limit amount for the coverage.
POLICY COVERAGES
Limit Applies to:
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
POLICY COVERAGES
Deductible
Enter deductible: The deductible amount for the coverage.
POLICY COVERAGES
Deductible Applies to:
Enter code: The code identifying what the deductible applies to.
POLICY COVERAGES
Deductible
Enter deductible: The deductible amount for the coverage.
POLICY COVERAGES
Deductible Applies to:
Enter code: The code identifying what the deductible applies to.
POLICY COVERAGES
Deductible
Enter deductible: The deductible amount for the coverage.
ACORD 330 (2014/12) rev. 04-29-2014
Page 23 of 27
POLICY COVERAGES
Deductible Applies to:
Enter code: The code identifying what the deductible applies to.
POLICY COVERAGES
Premium
Enter amount: The premium amount for the coverage.
POLICY COVERAGES
Coverage Code
Enter code: The code for the coverage.
POLICY COVERAGES
Coverage Description
Enter text: The description of other coverage (not the limit) on the policy. Any questions about
appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s)
POLICY COVERAGES
Options Check Box
Check the box (if applicable): Indicates a coverage option applies to the coverage.
POLICY COVERAGES
Describe Option
Enter text: The description of the option being requested.
POLICY COVERAGES
Options Check Box
Check the box (if applicable): Indicates a coverage option applies to the coverage.
POLICY COVERAGES
Describe Option
Enter text: The description of the option being requested.
POLICY COVERAGES
Options Check Box
Check the box (if applicable): Indicates a coverage option applies to the coverage.
POLICY COVERAGES
Describe Option
Enter text: The description of the option being requested.
POLICY COVERAGES
Limit
Enter limit: The limit amount for the coverage.
POLICY COVERAGES
Limit Applies to:
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
POLICY COVERAGES
Limit
Enter limit: The limit amount for the coverage.
POLICY COVERAGES
Limit Applies to:
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
POLICY COVERAGES
Limit
Enter limit: The limit amount for the coverage.
POLICY COVERAGES
Limit Applies to:
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
POLICY COVERAGES
Deductible
Enter deductible: The deductible amount for the coverage.
POLICY COVERAGES
Deductible Applies to:
Enter code: The code identifying what the deductible applies to.
POLICY COVERAGES
Deductible
Enter deductible: The deductible amount for the coverage.
POLICY COVERAGES
Deductible Applies to:
Enter code: The code identifying what the deductible applies to.
POLICY COVERAGES
Deductible
Enter deductible: The deductible amount for the coverage.
POLICY COVERAGES
Deductible Applies to:
Enter code: The code identifying what the deductible applies to.
POLICY COVERAGES
Premium
Enter amount: The premium amount for the coverage.
GENERAL INFORMATION
1. Does the applicant own
any other aircraft not listed?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Does the applicant own any other aircraft not listed?.
GENERAL INFORMATION
Explain
Enter text: An explanation as to whether the applicant owns any other aircraft not listed.
GENERAL INFORMATION
Aircraft Registration #
Enter identifier: The registration number of the aircraft (a.k.a. tail number).
ACORD 330 (2014/12) rev. 04-29-2014
Page 24 of 27
GENERAL INFORMATION
2. Does the aircraft have
other than a standard
airworthiness certificate in
full force and effect?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Does the aircraft have other than a standard airworthiness certificate in full force and effect?.
GENERAL INFORMATION
Explain
Enter text: An explanation as to whether the aircraft has other than a standard airworthiness
certificate in full force and effect.
GENERAL INFORMATION
Aircraft Registration #
Enter identifier: The registration number of the aircraft (a.k.a. tail number).
GENERAL INFORMATION
3. Has aircraft been
equipped with any
modifications not provided
by the original manufacturer
that alter the flying
characteristics?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Has aircraft been equipped with any modifications not provided by the original aircraft
manufacturer that alter the flying characteristics?.
GENERAL INFORMATION
Explain
Enter text: An explanation as to whether the aircraft has been equipped with any modification
not provided by the original manufacturer that alter the flying characteristics.
GENERAL INFORMATION
Aircraft Registration #
Enter identifier: The registration number of the aircraft (a.k.a. tail number).
GENERAL INFORMATION
4. Do you anticipate the
aircraft to be operated
outside the contiguous
United States?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Do you anticipate aircraft to be operated outside the contiguous United States?.
GENERAL INFORMATION
Explain
Enter text: An explanation as to whether you anticipate the aircraft will be operated outside the
contiguous United States.
GENERAL INFORMATION
Aircraft Registration #
Enter identifier: The registration number of the aircraft (a.k.a. tail number).
GENERAL INFORMATION
5. Is there any unrepaired
damage to the aircraft?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Is there any unrepaired damage to the aircraft?.
GENERAL INFORMATION
Explain
Enter text: An explanation as to whether there is any unrepaired to the aircraft.
GENERAL INFORMATION
Aircraft Registration #
Enter identifier: The registration number of the aircraft (a.k.a. tail number).
Form Page 4
Section Name
Field Name
Description
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g., agency or
brokerage).
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GENERAL INFORMATION
6. Will the aircraft be used
for any purpose(s) for which
a charge is made other than
those allowed in far part 91?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Will aircraft be used for any purpose(s) for which a charge is made other than those allowed in
FAR Part 91?.
GENERAL INFORMATION
Explain
Enter text: An explanation as to whether the aircraft will be used for any purpose(s) for which a
charge is made other than those allowed in far part 91.
GENERAL INFORMATION
Aircraft Registration #
Enter identifier: The registration number of the aircraft (a.k.a. tail number).
GENERAL INFORMATION
7. Will the aircraft be used
for other than the
transportation of persons
(such as hunting, aerial
applications, patrol,
research, etc.)?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Will aircraft be used for other than transportation of persons (such as hunting, aerial
applications, patrol, research, etc.)?.
GENERAL INFORMATION
Explain
Enter text: An explanation as to whether the aircraft will be used for other than the transportation
of persons (such as such as Hunting, Aerial Applications, Patrol, Research, etc.)
GENERAL INFORMATION
Aircraft Registration #
Enter identifier: The registration number of the aircraft (a.k.a. tail number).
GENERAL INFORMATION
8. Will the aircraft be used
for student or pilot
instruction other than for
recurrent training of named
pilots? If yes, provide all
details:
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Will aircraft be used for student or pilot instruction other than for recurrent training of named
pilots?
GENERAL INFORMATION
Explain
Enter text: An explanation as to whether the aircraft will be used for student or pilot instruction
other that for recurrent training of named pilots.
GENERAL INFORMATION
Aircraft Registration #
Enter identifier: The registration number of the aircraft (a.k.a. tail number).
GENERAL INFORMATION
9. Will the aircraft be
normally operated from
other than paved airports?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Will aircraft be normally operated from other than paved airports?.
GENERAL INFORMATION
Where
Enter text: The description of where the aircraft is used other than paved airports.
GENERAL INFORMATION
Purpose
Enter text: The purpose the aircraft is used in locations other than paved airports.
GENERAL INFORMATION
Frequency
Enter text: The frequency the aircraft is used in locations other than paved airports.
GENERAL INFORMATION
Aircraft Registration #
Enter identifier: The registration number of the aircraft (a.k.a. tail number).
GENERAL INFORMATION
10. Will the aircraft be
operated off airport?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Will the aircraft be operated off airport?.
ACORD 330 (2014/12) rev. 04-29-2014
Page 26 of 27
GENERAL INFORMATION
Explain
Enter text: An explanation as to whether the aircraft will be operated off airport.
GENERAL INFORMATION
Aircraft Registration #
Enter identifier: The registration number of the aircraft (a.k.a. tail number).
SIGNATURE
Producer's Signature
Sign here: Accommodates the signature of the authorized representative (e.g., producer, agent,
broker, etc.) of the company(ies) listed on the document. This is required in most states.
SIGNATURE
Producer's Name (Please
Print)
Enter text: The name of the authorized representative of the producer, agency and/or broker
that signed the form.
SIGNATURE
State Producer License No
(Required in FL)
Enter identifier: The State License Number of the producer.
SIGNATURE
Applicant's Signature
Sign here: Accommodates the signature of the applicant or named insured.
SIGNATURE
Date
Enter date: The date the form was signed by the named insured. (MM/DD/YYYY)
SIGNATURE
National Producer Number
Enter identifier: The National Producer Number (NPN) as defined in the National Insurance
Producer Registry (NIPR). Note: The NPN is not the same as the producer state license
number.
ACORD 330 (2014/12) rev. 04-29-2014
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