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WORKERS’ COMPENSATION SUPPLEMENTAL APPLICATION

Name of Account:

Your Name:
Address:
City:
State:
Zip:
Phone:
Email:

1. Total number of pilot or flying crew personnel?
Full time?   Part time?
2. Total number of ground crew or service personnel?
3. Total number of non-flying executives; sales or clerical?
4. Number, type and usage of aircraft:
  (a) Pleasure or business utility?
  (b) Commercial, i.e., charter, I&R?
  (c) Demo and sales?
  (d) Cargo and/or package transport?
  (e) Scheduled passenger carrier?
  (f) Other, i.e., firefighting, patrol, agriculture, etc.?
5. Year, make and model of all aircraft with more than 10 seats?
6. Year, make and model of jet aircraft?
7. Year, make and model of helicopters?
8. Any exposure to U.S. Acts coverage? USL&H? DBA? OCSA? FELA?
9. Any operations outside the Western Hemisphere?
10. Any antique, experimental or ex-military aircraft?
11. Any aerobatic, exhibition or racing aircraft?
12. Any dirigible or balloon exposure?
13. Any “scheduled” or repetitive aircraft operations?
14. Any seaplane, fish – spotting or maritime exposure?
15. Any large aircraft (FFA Part 121) exterior cleaning, stripping or painting?
16. Any rotor wing heavy lift, line stringing or logging operations?
17. Any agricultural or forestry operations?
18. Any contracts with the U.S. Armed Forces or other governmental agencies?
19. Any operations from unprepared sites?
20. Any leased or independent contractor employees?
21. Any independent contractors without workers’ compensation certificates?
22. Describe Safety & Loss Control Program:
(a) Written statement of safety policy? Yes No
(b) Written safety program with responsibility assigned? Yes No
(c) Regular safety meetings with documentation? Yes No
(d) Compliance with SARA “right to know statutes”? Yes No
(e) Have you been inspected by OSHA? Yes No

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