ࡱ> 02-./ @ bjbj (BF:0@@@8AD`BVvhD 2Q(ZQZQZQ9R9UVttttttt$wRz0t`5R9R``tZQZQveee`j8ZQZQte`tee:k,kZQtD :0@ aAk 9m&v0VvKkR@za@zk@zkW|QZe\l]WWWtt36D ae^6 THE SCHANTZ AGENCY & T.H.E. INSURANCE COMPANY PO Box 51591, Jacksonville Beach, FL 32240 904-246-1018 Phone 904-246-5646 Fax  HYPERLINK "mailto:Balloonmeister@theschantzagency.com" Balloonmeister@theschantzagency.com www.theschantzagency.com HOT AIR BALLOON INSURANCE APPLICATION Name of Applicant Balloon owner  FORMTEXT       Phone  FORMTEXT       Address:  FORMTEXT       Trading Name?  FORMTEXT       E-mail Address:  FORMTEXT       Applicant is:  FORMCHECKBOX  Individual  FORMCHECKBOX  Corporation  FORMCHECKBOX  Partnership  FORMCHECKBOX  Other  FORMTEXT       Insurance is requested from (date)  FORMTEXT       20 FORMTEXT    through (date)  FORMTEXT       20 FORMTEXT    Is there any unrepaired damage to the balloon (minor or major)?  FORMCHECKBOX  Yes  FORMCHECKBOX  No if  Yes explain  FORMTEXT       LIABILITY COVERAGE A. Third Party Liability  Excluding Passengers (Check One)LIMITS OF LIABILITY  FORMCHECKBOX  $ 500,000 per Occurrence/$1,000,000 Aggregate  FORMCHECKBOX  $1,000,000 per Occurrence/$2,000,000 AggregateB. Passenger Liability $100,000 per passenger *C. Medical Expenses Including Pilot & Crew$5,000 per person* Passenger aggregate will be seating times passenger liability limit A PASSENGER WAIVER IS REQUIRED FOR ALL USE OF ANY INSURED BALLOON. 1. Do you use waivers and require them to be signed by all passengers?  FORMCHECKBOX  Yes  FORMCHECKBOX  No PHYSICAL DAMAGE COVERAGE F. ALL RISKS GROUND AND FLIGHT: Deductible $1,000. Choose Evaluation Method:  FORMCHECKBOX  Stated Value  FORMCHECKBOX  Actual Cash Value. Envelope, Gondola and Accessories values entered on page two.  PURPOSE OF USE Pleasure Use FORMTEXT       Hours flown last 12 monthsPleasure Use FORMTEXT       Hours to be flown next 12 months Instruction FORMTEXT       Hours flown last 12 monthsInstruction FORMTEXT       Hours to be flown next 12 months Commercial (Fare Paying) Use FORMTEXT       Hours commercial use last 12 monthsCommercial (Fare Paying) Use  FORMTEXT       Hours commercial use next 12 months BALLOON INFORMATION Balloon #1Balloon #2Balloon #3Balloon #4Balloon #5Year Built  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Make FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Model FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT        N Number FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FAA Balloon Size Category AX  FORMTEXT        AX  FORMTEXT       AX  FORMTEXT       AX  FORMTEXT       AX  FORMTEXT       Gondola Serial No. FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Date Purchased FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       New or Used? FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Envelope Value * Only if Coverage desired$  FORMTEXT      $  FORMTEXT       $  FORMTEXT      $  FORMTEXT      $  FORMTEXT      Gondola Value* Min $2500. if desired (includes burners, frames and tanks)$  FORMTEXT      $  FORMTEXT       $  FORMTEXT      $  FORMTEXT      $  FORMTEXT      Accessories Value* $  FORMTEXT      $  FORMTEXT       $  FORMTEXT      $  FORMTEXT      $  FORMTEXT       Cubic Feet FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Date of Last Inspection FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Inspector s Name FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Max passenger capacity excluding pilot FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Total Hours on Balloon FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       # of Hours per year FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Airworthiness Cert. Current? FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       * Enter Insurance Amounts Here if Desired.  Enter the number of balloons in flight at any one time:  FORMTEXT       Note: Coverage Does Not Apply To Alaska, Hawaii & Mexico. Coverage Does Not Automatically Apply Outside The United States. Contact Company with Details if Coverage Is Required For Canada. Please Submit. How frequently does applicant use non-owned balloon?  FORMTEXT       Will balloon be used for student or pilot instruction?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If  Yes explain  FORMTEXT       Are other balloons owned by applicant?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If  Yes list make(s), model(s) and FAA N Number(s)  FORMTEXT       Additional insured Certificates are available on a by request basis. Please provide legal name of the Additional Insured, address, contact info and what their interest is. A $50 premium applies to each Additional Insured, payable at time of request. LOSS HISTORY AND PREVIOUS AVIATION INSURANCE PLEASE EXPLAIN EACH YES ANSWER BELOW 1. Has applicant had any balloon/aviation losses, claims or incidents during the last five years?  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMTEXT       2. Has any insurer cancelled, declined, sent notice of cancellation, or refused to renew any aviation insurance?  FORMCHECKBOX  Yes  FORMCHECKBOX  No (not applicable in the following states: Missouri).  FORMTEXT       3. Name of Last % or Present % Balloon Insurance Company  FORMTEXT       Expiration date  FORMTEXT       PILOT INFORMATION  YOU MUST COMPLETE A SEPARATE PILOT INFORMATION FORM (HABAPP PIC 0409) FOR EACH PILOT WHO WILL OPERATE THE BALLOON All Particulars herein are warranted true and complete to the best of my knowledge and no information has been withheld or suppressed and I/we agree that this Application and the terms and conditions of the policy in use by the insurer shall be the basis of any contract between me/us and the insurer. I hereby authorize this Company to investigate all or any qualifications or statements contained herein. FRAUD WARNING (All States except: AR; CO; DC; FL; HI; KY; ME; MD; NJ; NY; OH; OK; OR; PA; VT) Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties. Arkansas Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Colorado It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the department of regulatory agencies. District of Columbia It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant. Florida Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. Kentucky Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime. Maine It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits. Maryland Any person who, with intent to defraud or knowingly that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may be guilty of insurance fraud. New Jersey Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. 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Ohio  Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against any insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud, which is a crime. Oklahoma  Any person who knowingly and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. Oregon  Any person who, with intent to defraud or knowingly that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may be guilty of insurance fraud. Pennsylvania  Any person who knowingly and with intent to injure or defraud any insurer files an application or claim containing any false, incomplete or misleading information shall, upon conviction, be subject to imprisonment for up to 7 years and payment of a fine of up to $15,000. Vermont  Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance may be guilty of a crime and may be subject to civil fines and criminal penalties. Date FORMTEXT       Applicant s Signature or type Full Name  FORMTEXT       All Owners Must Sign This application does not commit the Company to any liability nor make the Applicant liable for any premium unless the Company agrees to affect this insurance. THE SCHANTZ AGENCY & T.H.E. INSURANCE COMPANY PILOT INFORMATION Pilot Name: FORMTEXT      Phone:  FORMTEXT      Street Address: FORMTEXT      E-Mail: FORMTEXT      City, State, Zip:  FORMTEXT      Pilot License Number:  FORMTEXT      Date of Birth:  FORMTEXT      Limitations:  FORMTEXT      No. of Years Flying:  FORMTEXT      Date of Last Biennial:  FORMTEXT      Total Hours Flown as PIC:  FORMTEXT      Drivers License Number:  FORMTEXT      Number of Hours Last 12 Months:  FORMTEXT      Have you attended a Safety Seminar in Last 12 Months:  FORMCHECKBOX  Yes  FORMCHECKBOX  No If Yes, please enter Seminar name and date:  FORMTEXT      Total Hours As PIC in AX6 (2 Passengers)  FORMTEXT      Total Hours Last 12 Months:  FORMTEXT       Total Hours Est. Next 12 Months  FORMTEXT      Total Hours As PIC in AX7 (3 Passengers)  FORMTEXT      Total Hours Last 12 Months:  FORMTEXT       Total Hours Est. Next 12 Months:  FORMTEXT      Total Hours As PIC in AX8B (4 Passengers)  FORMTEXT      Total Hours Last 12 Months:  FORMTEXT       Total Hours Est. Next 12 Months:  FORMTEXT      Total Hours As PIC in AX8 (5 Passengers)  FORMTEXT      Total Hours Last 12 Months:  FORMTEXT       Total Hours Est. Next 12 Months:  FORMTEXT      Total Hours As PIC in AX9 (6 Passengers)  FORMTEXT      Total Hours Last 12 Months:  FORMTEXT       Total Hours Est. Next 12 Months:  FORMTEXT      Total Hours As PIC in AX10C (7 Passengers)  FORMTEXT      Total Hours Last 12 Months:  FORMTEXT       Total Hours Est. Next 12 Months:  FORMTEXT      Total Hours As PIC in AX10B (8 Passengers)  FORMTEXT      Total Hours Last 12 Months:  FORMTEXT       Total Hours Est. Next 12 Months:  FORMTEXT      Total Hours As PIC in AX10 (10 Passengers)  FORMTEXT      Total Hours Last 12 Months:  FORMTEXT       Total Hours Est. Next 12 Months:  FORMTEXT       DISCLOSURE INFORMATION: EXPLAIN YES ANSWERS BELOW Have you ever been involved in any aircraft incident or accident, including Property Damage? FORMCHECKBOX  Yes  FORMCHECKBOX  NoHave you ever been cited by a regulatory authority? FORMCHECKBOX  Yes  FORMCHECKBOX  NoHas your license ever been suspended or revoked? FORMCHECKBOX  Yes  FORMCHECKBOX  NoHave you ever been charged with DUI or DWI? FORMCHECKBOX  Yes  FORMCHECKBOX  NoHave you ever had an application for aviation insurance denied? FORMCHECKBOX  Yes  FORMCHECKBOX  NoExplain  YES answers here:  FORMTEXT       By signing below, I hereby represent that all information is true and I have completed this from personally. I also agree to allow the company to investigate my FAA records, Motor Vehicle Records and credit or other background reports. Signature or Typed Full Name:  FORMTEXT       Date:  FORMTEXT       COVERAGE APPLIES ONLY TO PILOTS NAMED ON THE POLICY. ALL PILOTS PROPOSED FOR COVERAGE MUST HAVE A FULLY COMPLETED AND SIGNED PILOT INFORMATION QUESTIONNAIRE.     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