COI Expires 03/24/2018AVIATION COMMERCIAL GENERAL LIABILITY
DECLARATIONS
POLICY NUMBER: AP 023405298-04 PREVIOUS POLICY NUMBER: AP 023405298-03
ISSUED BY:
PRODUCER:
NATIONAL UNION FIRE INSURANCE COMPANY OF
TORELL INSURANCE AGENCY, INC.
PITTSBURGH, PA
18604 KITTY HAWK COURT, STE. H
175 WATER STREET, 18TH FLOOR
PORT SAINT LUCI, FL 34987
NEW YORK, NY 10038
NAMED INSURED:
ANTIQUE AIRCRAFT RESTORATION, INC.
WANE /A U_�S
Fie
MAILING ADDRESS:
't"l
7500 GULFSTREAM BLVD.
MARATHON, FL 33050
POLICY PERIOD: FROM March 24, 2017
TO March 24, 2018 AT 12:01 A.M. TIME
AT YOUR MAILING ADDRESS SHOWN ABOVE
IN RETURN FOR THE PAYMENT OF THE PREMIUM, AND SUBJECT TO ALL THE TERMS OF THIS
POLICY, WE AGREE WITH YOU TO PROVIDE THE INSURANCE AS STATED IN THIS POLICY.
LIMITS OF INSURANCE
EACH OCCURRENCE LIMIT
$
1,000,000.
DAMAGE TO PREMISES
RENTED TO YOU LIMIT
$
100,000.
Any one premises
MEDICAL EXPENSE LIMIT
$
5.000.
Any one person
PERSONAL & ADVERTISING INJURY AGGREGATE LIMIT
$ 1,000,000.
GENERAL AGGREGATE LIMIT
$ NOT APPLICABLE
PRODUCTS/COMPLETED OPERATIONS AGGREGATE LIMIT
$ 1,000,000,
HANGARKEEPERS LIMIT
EACH AIRCRAFT LIMIT
$
1,000,000.
EACH LOSS LIMIT
$
500,000.
HANGARKEEPER'S DEDUCTIBLE
$
5.000.
Each aircraft
DESCRIPTION OF BUSINESS
FORM OF BUSINESS:
❑ INDIVIDUAL ❑ PARTNERSHIP ❑ JOINT VENTURE ❑ TRUST
❑ LIMITED LIABILITY COMPANY X❑ ORGANIZATION, INCLUDING A CORPORATION (BUT
NOT INCLUDING A PARTNERSHIP, JOINT VENTURE
OR LIMITED LIABILITY COMPANY) 1.
BUSINESS DESCRIPTION: ANTIQUE AIRCRAFT RESTORATION COMPANY
CGL04 (2/05)
Includes copyrighted material of Insurance Services Office, Inc. with its permission
Page 1 of 2
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ALL PREMISES YOU OWN, RENT OR OCCUPY
ADDRESS OF ALL PREMISES YOU OWN, RENT OR OCCUPY
FLORIDA KEYS MARATHON AIRPORT
MARATH ON, FL
AND ALL PREMISES NECESSARY AND/OR INCIDENTAL TO THE AVIATION OPERATION OF NAMED
INSURED
PREMIUM
STATE TAX OR OTHER (if applicable) $ NOT APPLICABLE
PREMIUM SHOWN AT INCEPTION IS PAYABLE: Annually $ 10,000.00
TRIA PREMIUM: Not Purchased
ENDORSEMENTS
I ENDORSEMENTS ATTACHED TO THIS POLICY I
SEE ATTACHED FORMS SCHEDULE
THESE DECLARATIONS, TOGETHER WITH THE COMMON POLICY CONDITIONS AND COVERAGE
FORM(S) AND ANY ENDORSEMENT(S), COMPLETE THE ABOVE NUMBERED POLICY
Countersigned:
Approved By: I W�7d�al - -
� —�—
(Authorized Representative)
Date of Issue March 23, 2017 AM
CGL04 (2/05)
Includes copyrighted material of Insurance Services Office, Inc. with its permission
Page 2 of 2
FORMS SCHEDULE
POLICYHOLDER ANTIQUE AIRCRAFT RESTORATION, INC.
POLICY NO. AP 023405298-04
POLICY PERIOD: From March 24, 2017 to March 24, 2018
The following forms are attached to the policy at inception.
FORM NUMBER AND
VERSION DATE
FORM TITLE
CGL04 (02-05)
Aviation Commercial General Liability Declarations
CGL02-NU (02-05)
Commercial General Liability Coverage Form
CGL56 (03-05)
Financed Premium Endorsement
UE882 (01-05)
Asbestos Exclusion Endorsement
UE38B (01-05)
Nuclear Risks Exclusion Clause AVN38B
UE2000A (01-05)
Date Recognition Exclusion Clause AVN2000A
CGL2002A (03-05)
Date Recognition Limited Coverage Clause AVN2002A
UE46B (01-05)
Noise and Pollution and Other Perils Exclusion Clause AVN46B
UE1066 (01-15)
Terrorism Exclusion - Certified Acts
UE48B (01-05)
War Hi -jacking and Other Perils Exclusion Clause Aviation AVN48B
CGL191 (03-05)
Additional Insured - Designated Person or Organization
UE38 (01-05)
Countersignature Endorsement
UE1437 (06-14)
Sanctions and Embargo Clause - AVN111
76105 (06-15)
Florida Cancellation / Nonrenewal Endorsement
74825 (01-13)
Florida Addendum to the Declarations
UE1268 (02-10)
Florida Notice of Loss Control Services
91222 (09-16)
Policyholder Notice
All other provisions of this policy remain the same.
UE1276 (6/10) Page 1