Product Liability Form

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Product Liability

(Appropriate for Non Manufacturing Exposures and / or Ariel Form Section 3 - small to medium companies)

Name of InsuredName of Insured

Address of InsuredAddress of Insured

Telephone NumberTelephone Number

Name of any Subsidiaries with Aviation Products10. Name of any Subsidiaries with Aviation Products

Sales of all Products (USD)

Civil

Military

Past 12 months

Past 12 months - Civil

Past 12 months -Military

Fixed Wing

Fixed Wing - Civil

Fixed Wing - Military

Rotor Wing

Rotor Wing - Civil

Rotor Wing - Military

Total % split between Airframe and Engines / Propellers / Rotors

Total - Civil

Total - Military

Sales of Fuel (if any) and approximate gallonage per annum.

Sales of Fuel (if any) and approximate gallonage per annum. - Civil

Sales of Fuel (if any) and approximate gallonage per annum. - Military

Sales of all Products estimated for next 12 months

Sales of all Products estimated for next 12 months - Civil

Sales of all Products estimated for next 12 months - Military

Fixed Wing

Fixed Wing - Military

Fixed Wing - Civil

Rotor Wing

Rotor Wing Civil

Rotor Wing - Military

Total

Total - Civil

Total - Military

Name Customers that parts are sold to and name the types of engine / aircraft that they will be fitted into.Name Customers that parts are sold to and name the types of engine / aircraft that they will be fitted into.

% split between Airframe and Engines / Propellers / Rotors% split between Airframe and Engines / Propellers / Rotors

Sales of Fuel (if any) and approximate gallonage per annum.Sales of Fuel (if any) and approximate gallonage per annum.

How long has Insured been in the aviation business?How long has Insured been in the aviation business?

Description of products sold/suppliedDescription of products sold/supplied

What types of aircraft does Insured usually work on?What types of aircraft does Insured usually work on?

Does the Insured manufacture any aviation products? Please specify.Does the Insured manufacture any aviation products? Please specify.

Does the Insured represent any manufacturers of products? Please specify.Does the Insured represent any manufacturers of products? Please specify.

Has the Insured signed any aviation contracts that include additional Insured, hold harmless, waiver of subrogation or indemnity provisions that may affect this insurance? As far as known has the Insured exposed itself, or, protected itself when signing contracts affecting this insurance?Has the Insured signed any aviation contracts that include additional Insured, hold harmless, waiver of subrogation or indemnity provisions that may affect this insurance? As far as known has the Insured exposed itself, or, protected itself when signing contracts affecting this insurance?

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Does the Insured do any business with customers or agents domiciled in the USA?Does the Insured do any business with customers or agents domiciled in the USA?

Describe the experience and general training levels of Insured's aviation personnel.Describe the experience and general training levels of Insured's aviation personnel.

Have any claims been made against the Insured during the past 10 years? If so, what were the details and amounts involved?Have any claims been made against the Insured during the past 10 years? If so, what were the details and amounts involved?

If previously uninsured, give details of any payments made to claimants.If previously uninsured, give details of any payments made to claimants.

Does the Insured currently buy aviation products liability coverage? If so, with whom?Does the Insured currently buy aviation products liability coverage? If so, with whom?

All aviation products liability policies contain an aggregate limit of liability. What limit of liability do you require?All aviation products liability policies contain an aggregate limit of liability. What limit of liability do you require?

Please provide any other information which you feel may be relevant to this proposal.Please provide any other information which you feel may be relevant to this proposal.

Summary of Products Liability coverage provided

Bodily Injury or property damage arising out of the possession, use, consumption or handling of any goods or products manufactured, constructed, altered, repaired, serviced, treated, sold, supplied or distributed by the Insured or his employees after such Aviation goods or Aviation products have ceased to be in the possession or under the control of the Insured.

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