CAMPBELL RISK MAMAGEMENT

9595 Whitley Drive #204Indianapolis, IN46048 Ph: (800) 730-7475 Fax: (317) 848-9093

Balloon Insurance Application
APPLICATION MUST BE FULLY COMPLETED
Effective From / Until / At 12:01 AM Standard Time At The Address Below.
AMOUNT OF LIABILITY COVERAGE DESIRED:
Present Insurance Carrier? / Expiration Date?
How Long Insured?
APPLICANT INFORMATION: / Phone Numbers
Name: / Bus:
DBA: / Fax:
Applicant is: / Individual(s) / Partnership / Corporation / LLC / Other
Address:
City: / State: / Zip:
Mailing Address:
City: / State: / Zip:
Any Anticipated Use Outside Of The U.S.A. (if yes, where?)
BALLOON SCHEDULE:
Year: / Make: / Model: / Registration Number:
Envelope Size (Cu. Ft.) / #Of Burners: / Desired Capacity Excluding PIC:
Purchase Date: / Purchase Price: / Estimated Current Value:
Aircraft Usually Based At:
Does Applicant Hanger, Service, Repair or Crew Other Aircraft?
Describe:
Is Any Aircraft Registered Under Other Names Than Applicant's Name Above?
Describe:
Applicant is: / Sole Owner of Aircraft / Owner Subject to Mortgage or Conditional Sales Contract
Other-Explain:
If Aircraft Mortgaged, Name and Address of Mortgagee: / Name:
Address:
City: / State: / Zip:
Date of Last 100 Hour or Annual Inspection: / Total Hours on Balloon:
Inspectors Name: / Inspectors Phone #:
Estimated Hours For Next 12 Months: / Usage of Balloon:
Any Major Fabric Replacement? / If so, what date?
Basket Manufacturer: / Age of Basket: / Is Basket Partitioned:
Fuel Hoses Replaced? / What date? / Number and Capacity of Fuel Tanks:
Has any individual, partnership or corporation herein been involved in any aviation accident, incident, or loss
including personal injury to pilot and/or passengers? / Yes / No / If so, provide details on other pages.
Applicants Signature: / Application Date:
NAME: / DBA:
BALLOON SCHEDULE:
Continued
Year: / Make: / Model: / Registration Number:
Envelope Size (Cu. Ft.) / #Of Burners: / Desired Capacity Excluding PIC:
Purchase Date: / Purchase Price: / Estimated Current Value:
Aircraft Usually Based At:
Does Applicant Hanger, Service, Repair or Crew Other Aircraft?
Describe:
Is Any Aircraft Registered Under Other Names Than Applicant's Name Above?
Describe:
Applicant is: / Sole Owner of Aircraft / Owner Subject to Mortgage or Conditional Sales Contract
Other-Explain:
If Aircraft Mortgaged, Name and Address of Mortgagee: / Name:
Address:
City: / State: / Zip:
Date of Last 100 Hour or Annual Inspection: / Total Hours on Balloon:
Inspectors Name: / Inspectors Phone #:
Estimated Hours For Next 12 Months: / Usage of Balloon:
Any Major Fabric Replacement? / If so, what date?
Basket Manufacturer: / Age of Basket: / Is Basket Partitioned:
Fuel Hoses Replaced? / What date? / Number and Capacity of Fuel Tanks:
Year: / Make: / Model: / Registration Number:
Envelope Size (Cu. Ft.) / #Of Burners: / Desired Capacity Excluding PIC:
Purchase Date: / Purchase Price: / Estimated Current Value:
Aircraft Usually Based At:
Does Applicant Hanger, Service, Repair or Crew Other Aircraft?
Describe:
Is Any Aircraft Registered Under Other Names Than Applicant's Name Above?
Describe:
Applicant is: / Sole Owner of Aircraft / Owner Subject to Mortgage or Conditional Sales Contract
Other-Explain:
If Aircraft Mortgaged, Name and Address of Mortgagee: / Name:
Address:
City: / State: / Zip:
Date of Last 100 Hour or Annual Inspection: / Total Hours on Balloon:
Inspectors Name: / Inspectors Phone #:
Estimated Hours For Next 12 Months: / Usage of Balloon:
Any Major Fabric Replacement? / If so, what date?
Basket Manufacturer: / Age of Basket: / Is Basket Partitioned:
Fuel Hoses Replaced? / What date? / Number and Capacity of Fuel Tanks:
NAME: / DBA:
BALLOON SCHEDULE:
Continued
Year: / Make: / Model: / Registration Number:
Envelope Size (Cu. Ft.) / #Of Burners: / Desired Capacity Excluding PIC:
Purchase Date: / Purchase Price: / Estimated Current Value:
Aircraft Usually Based At:
Does Applicant Hanger, Service, Repair or Crew Other Aircraft?
Describe:
Is Any Aircraft Registered Under Other Names Than Applicant's Name Above?
Describe:
Applicant is: / Sole Owner of Aircraft / Owner Subject to Mortgage or Conditional Sales Contract
Other-Explain:
If Aircraft Mortgaged, Name and Address of Mortgagee: / Name:
Address:
City: / State: / Zip:
Date of Last 100 Hour or Annual Inspection: / Total Hours on Balloon:
Inspectors Name: / Inspectors Phone #:
Estimated Hours For Next 12 Months: / Usage of Balloon:
Any Major Fabric Replacement? / If so, what date?
Basket Manufacturer: / Age of Basket: / Is Basket Partitioned:
Fuel Hoses Replaced? / What date? / Number and Capacity of Fuel Tanks:
Year: / Make: / Model: / Registration Number:
Envelope Size (Cu. Ft.) / #Of Burners: / Desired Capacity Excluding PIC:
Purchase Date: / Purchase Price: / Estimated Current Value:
Aircraft Usually Based At:
Does Applicant Hanger, Service, Repair or Crew Other Aircraft?
Describe:
Is Any Aircraft Registered Under Other Names Than Applicant's Name Above?
Describe:
Applicant is: / Sole Owner of Aircraft / Owner Subject to Mortgage or Conditional Sales Contract
Other-Explain:
If Aircraft Mortgaged, Name and Address of Mortgagee: / Name:
Address:
City: / State: / Zip:
Date of Last 100 Hour or Annual Inspection: / Total Hours on Balloon:
Inspectors Name: / Inspectors Phone #:
Estimated Hours For Next 12 Months: / Usage of Balloon:
Any Major Fabric Replacement? / If so, what date?
Basket Manufacturer: / Age of Basket: / Is Basket Partitioned:
Fuel Hoses Replaced? / What date? / Number and Capacity of Fuel Tanks:
NAME: / DBA:
BALLOON SCHEDULE:
Continued
Year: / Make: / Model: / Registration Number:
Envelope Size (Cu. Ft.) / #Of Burners: / Desired Capacity Excluding PIC:
Purchase Date: / Purchase Price: / Estimated Current Value:
Aircraft Usually Based At:
Does Applicant Hanger, Service, Repair or Crew Other Aircraft?
Describe:
Is Any Aircraft Registered Under Other Names Than Applicant's Name Above?
Describe:
Applicant is: / Sole Owner of Aircraft / Owner Subject to Mortgage or Conditional Sales Contract
Other-Explain:
If Aircraft Mortgaged, Name and Address of Mortgagee: / Name:
Address:
City: / State: / Zip:
Date of Last 100 Hour or Annual Inspection: / Total Hours on Balloon:
Inspectors Name: / Inspectors Phone #:
Estimated Hours For Next 12 Months: / Usage of Balloon:
Any Major Fabric Replacement? / If so, what date?
Basket Manufacturer: / Age of Basket: / Is Basket Partitioned:
Fuel Hoses Replaced? / What date? / Number and Capacity of Fuel Tanks:
Year: / Make: / Model: / Registration Number:
Envelope Size (Cu. Ft.) / #Of Burners: / Desired Capacity Excluding PIC:
Purchase Date: / Purchase Price: / Estimated Current Value:
Aircraft Usually Based At:
Does Applicant Hanger, Service, Repair or Crew Other Aircraft?
Describe:
Is Any Aircraft Registered Under Other Names Than Applicant's Name Above?
Describe:
Applicant is: / Sole Owner of Aircraft / Owner Subject to Mortgage or Conditional Sales Contract
Other-Explain:
If Aircraft Mortgaged, Name and Address of Mortgagee: / Name:
Address:
City: / State: / Zip:
Date of Last 100 Hour or Annual Inspection: / Total Hours on Balloon:
Inspectors Name: / Inspectors Phone #:
Estimated Hours For Next 12 Months: / Usage of Balloon:
Any Major Fabric Replacement? / If so, what date?
Basket Manufacturer: / Age of Basket: / Is Basket Partitioned:
Fuel Hoses Replaced? / What date? / Number and Capacity of Fuel Tanks: