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Airport Liability Application Form
GSIS application form for airport liability
Your Browser Doesn't Support Canvas. Showing the Text Content of the PDF Instead: PASEGURUHAN NG MGA NAGLILINGKOD SA PAMAHALAAN
(GOVERNMENT SERVICE INSURANCE SYSTEM)
Financial Center, Pasay City, Metro Manila
GSIS Headquarters Building
Financial Center, Pasay City
Telephone No.: 479-3670
Fax No.: 8590-314
AIRPORT LIABILITY APPLICATION FORM
Applicant’s Name: _______________________________________________________________________
Mailing Address:
________________________________________________________________________
________________________________________________________________________
Effective:
From ____________________________
until _____________________________________
BOTH AT 12:01 A.M., standard time at the address in item 2 above.
Applicant is:
□ Government
□ Partnership (name all partners) ___________________________________
□ Corporation
_________________________________________________________________
□ Estate
□ Others (describe) _______________________________________________
GENERAL INFORMATION
Name & Location of this Airport (this application is only for one airport location)
__________________________________________________________________________________________
__________________________________________________________________________________________
Applicant interest in Airport is:
□ Owner
□ Lessor
Application is:
□ Trustee
□ Other (describe) ___________________________
□ Lessee
If Applicant is Government:
a) Does airport board/authority/commission or transportation authority operate airport?
□ Yes
□No
b) Does applicant submit airport insurance for public bid annually?
□ Yes
□ No
c) Does applicant maintain insurance for all other non-airport operations through
commercial insurance carriers? □ Yes
□ No
If Yes to c, show:
Limits: $ _______________ Expiration _______________ Deductible/S.I.R.: $ _________________
If No to c, describe program fully:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________ _________________________________________(use extra paper to provide full description)
d) Airport Budget Last Year:
FAA Airport Classification
$_______________________ This Year:
$_______________________
_____________________________________________________________
Government Service Insurance System
Airport Liability Application Form
Page 2 of 7
List certificate restrictions and exemptions
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
PREMISES – OPERATIONS
Control Tower Operation:
□No Control Tower
□ FAA Tower
□Other – Operated by:
________________________________________________________________________________________
________________________________________________________________________________________
Operating Days/Hours are:
________________________________________________________________________________________
Applicant:
□ Does
□Does Not Operate Unicom Service
Are any Navaids, Radars, Windshear detectors or aircraft communications owned, leased or
maintained by applicant?
□Yes
□ No
Describe:_________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Runways, Taxiways, Ramps inspected/maintained by: □Applicant
□Other (name of Firm)
_________________________________________________________________________________________
_________________________________________________________________________________________
Does applicant maintain/operate fuel storage facilities?
a.) If “yes” to above, tanks are: □above ground
□Yes
□No
□below ground
b.) Frequency of inspections _____________________________________________________________
Non-Aviation activities on Airport: □ Lodging
□Farming
□Industrial Park
□Storage
□Others: (Describe All Non-Aviation Activities)
___________________________________________________________________________________
Does Applicant:
a.) Maintain Air Crash emergency Plan? □Yes
b.) Maintain Anti-Terrorist Plan?
□Yes
□No
c.) Employ Medical Personnel?
□Yes
□No
□No
Do they have separate insurance coverage?
□Yes
□No
Describe __________________________________________________________________________
d.) Base Fire Fighting vehicles on the airport full time?
□Yes
□No
If No, distance to nearest Fire Department ________________________ Kilometers/Miles
e.) Maintain Wildlife and Bird Strike prevention program?
□Yes
□No
f.) Own, operate, use or maintain any off-Airport premises to be covered?
□Yes
□No
Describe all locations and uses:
__________________________________________________________________________________________
Government Service Insurance System
Airport Liability Application Form
Page 3 of 7
g.) Charge for auto parking?
□Yes
h.) Host/sponsor or operate Airshows?
□No
Number of parking spaces: ________________
□Yes
□No
Describe _________________________________________________________________________________
i.) (i) Number of:
Elevators
Escalators
Moving Sidewalks
Automated Passenger
Trains
Automatic Doors
(ii) Who maintains?
__________________________________________________________________________________________
Is Airport completely fenced in?
□Yes
□No
a.) Airport security is provided by:
__________________________________________________________________________________________
b.) Frequency of patrols: ________________________________________________________________
Do they have separate insurance coverage?
□Yes
□No
Estimated number of aircraft movements this year for:
a.) General aviation ________________________
b.) Commuter airlines _____________________
c.) Other airlines ___________________________
d.) Military _______________________________
TOTAL: ________________________
Estimated number of enplaned passengers this year: ______________________________________
Largest Aircraft using Airport (make and model)
__________________________________________________________________________________________
By (name of operator):
_________________________________________________________________________________________
Runways:
HEADING
LENGTH
WIDTH
SURFACE
DESCRIBE ALL OBSTRUCTIONS
List all Air Carriers using the Airport
__________________________________________________________________________________________
__________________________________________________________________________________________
Government Service Insurance System
Airport Liability Application Form
Page 4 of 7
PRODUCTS/COMPLETED OPERATIONS
Does Applicant engage in:
YES/NO
GROSS SALES
LAST YEAR
ESTIMATED
THIS YEAR
a.) Aircraft Fuelling (gallons)
_____
$______________
$______________
b.) Aircraft Maintenance/Repairs
_____
$______________
$______________
c.) Aircraft Parts/Accessories Sales
_____
$______________
$______________
d.) Cargo/Baggage Handling or Storage _____
$______________
$______________
e.) Jetway or Planemate Operation
_____
$______________
$______________
f.) Passenger or Baggage Security Operations _____
$______________
$______________
g.) Aircraft Towing
_____
$______________
$______________
h.) Aircraft De-icing
_____
$______________
$______________
i.) Restaurant/Vending Machine Operations
_____
$______________
$______________
j.) Airline ground support services
_____
$______________
$______________
k.) Control Tower
_____
$______________
$______________
l.) Other
_____
$______________
$______________
(List All Other Operations)
HANGARKEEPERS LIABILITY (AIRCRAFT IN YOUR CUSTODY FOR STORAGE / SAFEKEEPING / REPAIR / SERVICING)
a.) Number of hangars __________
b.) Number of tie-down/parking spaces ____________
c.) Describe each hangar (show age, construction materials, size and if with sprinkler)
________________________________________________________________________________________
_________________________________________________________use extra papers to provide full description)
d.) Average value any one aircraft
$______________
Average total
______________
e.) Maximum value any one aircraft
$______________
Total all aircraft
______________
f.) Maximum value:
(i) any one hangar $________________
(ii) any on tie-down ramp $________________
LAST YEAR
g.) Gross sales for (i) Hangar rental/lease
(ii) Tie down rental/lease
$___________________
$___________________
ESTIMATED THIS YEAR
$___________________
$___________________
CONSTRUCTION, DEMOLITION & ALTERATIONS
Contract costs this year for:
RUNWAYS
OTHER
DESCRIBE WORK
a.) By Applicant
$______________
$______________ _____________________
b.) By Independent Contractors
$______________
$______________
_____________________
Government Service Insurance System
Airport Liability Application Form
Page 5 of 7
Is there an owner’s controlled insurance program?
□Yes
□No
□Limit $ ________________
If No, minimum limit required of independent contractors: $ _____________________________
Is applicant included as additional insured:
□Yes
□No
CONTRACTUAL LIABILITY – CONTRACTS HELD WITH THE FOLLOWING OPERATIONS:
Is Applicant Held
Designated Contracts
Minimum Required Limits
Is Applicant
Harmless?
Additional Insured?
a) Commuters & Airlines
$
□Yes
□No
□Yes
□No
b) Fixed Base Operators
$
□Yes
□No
□Yes
□No
c) Concessionaires
$
□Yes
□No
□Yes
□No
d) Contractors
$
□Yes
□No
□Yes
□No
e) Control Tower Operator
$
□Yes
□No
□Yes
□No
□Yes
□No
□Yes
□No
□Yes
□No
□Yes
□No
f)
Janitors, escalator
maintenance, security
$
g) Others
h.) Any contracts in which you assume the liability of others?
□Yes
□No
(If Yes, attach copies of contracts)
APPLICANTS VEHICLES:
Identify the number of vehicles owned by, operated by or leased to Applicant:
Snow Removal Equipment
Fuel Trucks
Sweepers
Tugs
Crash-fire-rescue vehicles
Hydrant carts
Passenger Cars
Pick-up Trucks
Passenger busses over 30 seats
Passenger busses under 30 seats
Others
Describe any operation of vehicle off airport premises: _____________________________________
__________________________________________________________________________________________
Does applicant maintain automobile liability coverage?
□Yes
□No
Limit? ____________________________________________________________________________________
CURRENT INSURANCE
Name of Insurance Company: ____________________________________________________________
Expiration Date: __________________________________________________________________________
Government Service Insurance System
Airport Liability Application Form
Page 6 of 7
Coverages:
__________________________________________________________________________________________
__________________________________________________________________________________________
Limits: ____________________________________________________________________________________
Deductible: $
_____________________________
Premium: $ ______________________________
POLICY DEDUCTIBLE
Each Occurrence: $ _______________________
Annual Aggregate: $______________________
Other coverages, restrictions, endorsements:
__________________________________________________________________________________________
__________________________________________________________________________________________
NON-OWNED AIRCRAFT: Provide following information with respect to non-owned aircraft
operated by or on behalf of the airport:
Does airport use non-owned aircraft on airport business?
□Yes
If yes, do employees pilot aircraft on airport business?
□No
□Yes
□No
Describe types of aircraft flown on airport business:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
By Employees
By Others
Number of hours flown annually in all non-owned aircraft
on applicant’s business
Number of hours flown annually in all non-owned aircraft
on applicant’s business
Number of hours flown in rented/leased aircraft
Number of hours flown in borrowed aircraft
Provide current pilot experience forms for each employee pilot.
__________________________________________________________________________________________
__________________________________________________________________________________________
CLAIMS: List all claims for past 5 years – use separate paper to complete
DATE
CAUSE
SETTLED, INCLUDING ALL COSTS
OPEN, INCLUDING RESERVES FOR
DEFENSE AND SETTLEMENT
Government Service Insurance System
Airport Liability Application Form
Page 7 of 7
COVERAGES & LIMITS REQUESTED
Coverage
Limits of Insurance
Commercial General Liability Coverage
General Aggregate Limit
(other than Products/Completed Operations)
$_____________________________
Products/Completed Operations Aggregate Limit
$_____________________________
Personal and Advertising Injury Aggregate Limit
$_____________________________
Each Occurrence Limit
$_____________________________
Fire Damage Limit (any one fire)
$_____________________________
Medical Expense Limit (any one person)
$_____________________________
Hangarkeeper’s Liability Coverage
Each Aircraft Limit
$_____________________________
Each Loss Limit
$_____________________________
Deductible
(each aircraft)
_______________________________
APPLICANT’S SIGNATURE
$_____________________________
____________________________
DATE
NAME and DESIGNATION : _________________________________________________________________________
