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Home My WebLink AboutHLP2022-07573353 Peachtree Road NE, Suite 1000 Atlanta, GA 30326 Certificate of Insurance Certificate Number:2.1 Issued By and Date:FEBRUARY 15, 2022 (AR) By Starr 10200 (6/06)(Authorized Representative) This is to certify that the policy(ies) listed herein have been issued providing coverage for the listed insured as further described. This certificate of insurance is not an insurance policy and does not amend, extend, or alter the coverage afforded by the policy(ies) listed herein. Notwithstanding any requirement, term or condition of any contract, or other document with respect to which this certificate of insurance may be concerned or may pertain, the Insurance afforded by the policy(ies) listed on this certificate is subject to all the terms, exclusions, and conditions of such policy(ies). Aircraft:Reg Insured Deductibles Year Make and Model No.Value NIM / IM Liability Limit - SEE ATTACHED ⠀ $ $ $ FLEET SCHEDULE - ⠀ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ THE CERTIFICATE HOLDER IS INCLUDED AS ADDITIONAL INSURED, BUT SOLELY AS RESPECTS THE OPERATIONS OF THE NAMED INSURED. THE INSURANCE EVIDENCED BY THIS CERTIFICATE SHALL NOT APPLY TO, AND NO PERSON OR ORGANIZATION TO WHICH COVERAGE IS EVIDENCED IN THE CERTIFICATE SHALL BE INSURED FOR BODILY INJURY OR PROPERTY DAMAGE WHICH ARISES FROM THE DESIGN, MANUFACTURE, MODIFICATION, REPAIR, SALE, OR SERVICING OF AIRCRAFT BY THAT PERSON OR ORGANIZATION. Certificate Holder:CITY OF GRAPEVINE 200 S. MAIN STREET GRAPEVINE, TX 76051 Named Insured:5-STATE HELICOPTERS, INC., CENTERPOINTE AEROSPACE AND AVIATION RESOURCES HOLDINGS LLC 285 BLACKLAND ROAD ROYSE CITY, TX 75189-4746 Policy Period: From:⠀FEBRUARY 15, 2022 ⠀To:⠀FEBRUARY 15, 2023 ⠀ Policy Number:SASICOM60184922-02 ⠀ Issuing Company:STARR INDEMNITY & LIABILITY COMPANY ⠀ 3353 Peachtree Road NE, Suite 1000 Atlanta, GA 30326 Issued By and Date:FEBRUARY 15, 2022 (AR) Certificate of Insurance – Fleet Schedule Attachment Named Insured:5-STATE HELICOPTERS, INC., CENTERPOINTE AEROSPACE AND AVIATION RESOURCES HOLDINGS LLC 285 BLACKLAND ROAD ROYSE CITY, TX 75189-4746 Policy Period:From:⠀February 15, 2022 ⠀To:⠀February 15, 2023 ⠀ Policy Number:SASICOM60184922-02 ⠀ Year Make and Model Reg No. Insured Value Deductibles NIM / IM Liability Limit Passenger Sublimit 1985 SIKORSKY UH-60A N244AA $2,000,000 10% OF IV / 10% OF IV $5,000,000 CSL INCL PAX 1990 EUROCOPTER BK 117 B- 1 N170MC $850,000 10% OF IV / 10% OF IV $5,000,000 CSL INCL PAX 1957 SIKORSKY S-58T N4XY $650,000 10% OF IV / 10% OF IV $5,000,000 CSL INCL PAX 1962 SIKORSKY S-58DT N9VY $650,000 10% OF IV / 10% OF IV $5,000,000 CSL INCL PAX Starr 10284 (3/06) ADDITIONAL INSURED ENDORSEMENT This policy is amended as follows: The provisions of this endorsement shall apply with respect to: (Only the clause(s) indicated by an "X" shall apply.) The scheduled persons or organizations are included as additional insured. The scheduled persons or organizations are the registered owner of and are included as additional insured. The scheduled persons or organizations are included as additional insured but only as respects liability coverages. The scheduled persons or organizations are included as additional insured under liability coverages, but only as respects operations of the named insured. The scheduled persons or organizations are included as additional insured but only as respects operations of the named insured. The insurance extended by this endorsement shall not apply to, and no person or organization named in the schedule shall be insured for bodily injury or property damage which arises from the design, manufacture, modification, repair, sale, or servicing of aircraft by that person or organization. Schedule: Name Address CITY OF GRAPEVINE 200 S. MAIN STREET GRAPEVINE, TX 76051 Name Address Name Address All other provisions of this policy remain the same. This endorsement becomes effective FEBRUARY 15, 2022 to be attached to and hereby made a part of: SASICOM60184922-02 5-STATE HELICOPTERS, INC., CENTERPOINTE AEROSPACE AND AVIATION RESOURCES HOLDINGS LLC By STARR INDEMNITY & LIABILITY COMPANY Endorsement No. TBA Date of Issue FEBRUARY 15, 2022 (AR) ⠀By (Authorized Representative) Policy No. Issued to CAP#________ DATE: TO: FAA OFFICE REFERENCE: CONGESTED / CONTINGENCY - SAFETY PLAN ** SHOULD A WEATHER, MECHANICAL OR MATERIAL DELAY BE EXPERIENCED, THIS PLAN IS APPROVED FOR ABOVE LISTED DATE PLUS 14 CALENDAR DAYS. ** AIRCRAFT INFORMATION: N6BL N4XY SIKORSKY S-58T TRANSPORT CATEGORY SIKORSKY S-58T TRANSPORT CATEGORY SIKORSKY S-58T TRANSPORT CATEGORY N9VY N170MC N60A MESSERSCHMITT TRANSPORT CATEGORY PILOT INFORMATION: ROBERT SMITH COMMERCIAL CERTIFICATE # 3493515 SHAWN HARRIS ATP # 2727633 ANDREW DALE COMMERCIAL CERTIFICATE # 3168484 PREPARED BY: APPROVED BY: OPERATING CERTIFICATE #LDUL599B 285 BLACKLAND ROAD FATE, TEXAS 75189 (972)636-4009 OFFICE@5STATE.COM WWW.5STATE.COM SIKORSKY UH-60A RESTRICTED CATEGORY JASON LACROSSE COMMERCIAL CERTIFICATE #2729162 031222A March 8, 2022 North Texas FSDO March 12, 2022 8:00AM 12:00PM Thred Up 801 Industrial BlvdGrapevine, TX 76051 24 Hour LTD8911 Directors Row Dallas, TX 75247 Toby Walters 469-853-8356Toby Walters 469-853-8356 Susan Bitros LOAD DESCRIPTION HAZMAT: YES (DOT-SP 16606 & DOT-SP 20490) NO ROOFTOP UNITS MATERIALS EQUIPMENT OTHER: NUMBER OF TOTAL LIFTS (RANGE) - WEIGHT RANGE - PERCENTAGE OF LIFT ABILITY OF AIRCRAFT LOAD AERODYNAMIC: YES NO LENGTH OF ATTACHING GEAR (FROM HOOK TO BOTTOM OF LOAD) BUILDING OCCUPIED DURING LIFT: YES NO * IF YES, ESTIMATED LOAD PENETRATION OF FLOORS AREA CONSIDERED CONGESTED: YES NO OPERATING CERTIFICATE # LDUL599B 285 BLACKLAND ROAD FATE, TEXAS 75189 (972) 636-4009 WWW.5STATE.COM XX XX 5 15 500 3,000 71% XX 85' XX XX 285 BLACKLAND ROAD FATE, TEXAS 75189 (972) 636-4009 WWW.5STATE.COM ______ CONGESTED COMMERCIAL AREA ______ CONGESTED RESIDENTIAL AREA ______ CONGESTED AREA PROBABILITY/POSSIBILITY This is congested area operations. Items are located in staging area(s) on either transportable vehicles or ground surface. Item(s) to be placed on building/structure roof top(s) or designated areas. Direct flight path(s) from staging area(s) to placement area(s) will occur unless otherwise notated on provided maps. Lift(s) amount(s), description(s), order and placement could be altered by contractor personnel, however, pick up site and drop site shall not be outside the parameter of this request. Helicopter landing area(s) will be secured at all times (prior, during and departure). Flight path(s) during lift operations inside the designated operational area(s) will remain clear of unauthorized personnel, equipment, obstacles at all times. Flight path(s) will remain within operational area(s) at all times. The operational area(s) has been surveyed for hazard(s) and mitigated to the lowest risk level acceptable to, or able to obtain, by both 5 State Helicopters, Inc. and contractor(s). Should a unforeseen, or additional hazard(s) surface, lifting will immediately halt till the hazard(s) have been rectified or mitigated. Primary means of communication via radio will be maintained constantly during the operation. Secondary means of communication via hand signals will be immediately incorporated should radio communications fail. Appropriate ATC communications will be maintained by pilot in all possible and/or feasible situations. Narrative: Due to the job-site being a warehouse in a commercial area we classify this to be a potential congested area. However, all entrances will be blocked and controlled by security personnel so that no unauthorized persons shall enter or cross the operational area. The building will be vacant inside the operational area during operations. XX 285 BLACKLAND ROAD FATE, TEXAS 75189 (972) 636-4009 office@5state.com www.5state.com Notification of Grapevine City Officials 5 State Helicopters has contacted the following city officials about the lift to be performed on March 12, 2022: 801 Industrial Blvd. Grapevine, TX 76051 City Manager: Connie Cook 817-410-3155 Your message has been delivered to the following recipients: Natasha Gale (nlgale@grapevinetexas.gov) Subject: 5 State Helicopter Lift of HVAC Equipment March 12, 2022 in Grapevine, TX at approximately 8:00 AM - 12:00 PM. Police: Mike Hamlin 817-410-3225 Your message has been delivered to the following recipients: 'mhamlin@grapevinetexas.gov' (mhamlin@grapevinetexas.gov) Subject: 5 State Helicopter Lift of HVAC Equipment 12 March 2022 in Grapevine, Texas at approximately 8:00AM-12:00PM. Fire: Darrell Brown 817-410-4400 Your message has been delivered to the following recipients: dbrown@grapevinetexas.gov (dbrown@grapevinetexas.gov) rbatchelor@grapevinetexas.gov (rbatchelor@grapevinetexas.gov) Subject: 5 State Helicopter Lift of HVAC Equipment 12 March 2022 in Grapevine, Texas at approximately 8:00AM-12:00PM ATC: Dallas Fort Worth Intl. Airport 972-615-2650 Your message has been delivered to the following recipients: Segleski, Matthew Y (FAA) (matthew.y.segleski@faa.gov) Lantz, Dallas W (FAA) (dallas.w.lantz@faa.gov) Short, John (FAA) (john.short@faa.gov) Subject: 5 State Helicopters lift operations 4 miles North West of DFW on March 12, 2022. Best Regards, 5 State Helicopters HOLD HARMLESS AND INDEMNITY AGREEMENT PROJECT ADDRESS: NATURE OF OPERATION: Helicopter externa! lift operation of Roof Top Units to building roof. DATE OF OPERATION: date mentioned. with rain date of with a 10 day grace period for each 1, Shawn Harris, the undersigned, representing 5-State Helicopters, lnc., binding my heirs, executors, administrators, estate and assigns, do hereby agree to completely and wholly release indemnify the hold harmless the city of Grapevine, its officers, agents, independent contractors, and employees from any and all claims, damages, personal injury, including death, property damage, lawsuits and judgments, including court costs, expenses and reasonable attorney's fees, and all other expenses resulting from any and all activities conducted within the city of Grapevine, Texas. lt is the understanding of all parties that this release, indemnity, and hold harmless agreement shall apply whether or not the claims, damages, harm, personal injury, including deaths, property damage, lawsuits, judgments, court costs, attorney's fees and any other expenses arise from the negligence of whatever nature, omissions, willful and intentional acts of this individual, company or company's officers, agents, employees, independent contractors, other representatives, invitee, licensee, or guests. 1, the undersigned individual and/or company company's officer, certifies, warrants and represents that the individual whose signature appears below is duly authorized to execute this agreement on behalf of the firms, corporation, partnership or other entity who will operate within the city of Grapevine, Texas. In witness whereof, this agreement has been executed this _ day of ____ 2022 COMPANY: 5-STATE HELICOPTERS, 1 STATE OF _______ COUNTY OF ________ _ This instrument was acknowledged befare me on this the __ day of ____ 2022 NOTARY PUBLIC IN AND FOR THE STATE OF ___ _ �y commiss�ion ex� es ------:d"-�'-;;;;;;::::;;:=S1gnature _...J44, �z ::>. l-� ,,uu,, i� .. -;f'-.�f'tli-, SUSAN BITROS f!f•:;..(:·:� Notary Public. State of Texas -.:�\.�_ .. ..,::: C m E · O -:-?j,• •••• ;;_..,...-� 0 m. xprres 8-26-2024,,, � OF -,v: ,, 11111111''' Notary ID 132643898 Thred Up801 Industrial Blvd.Grapevine, TX 76051 March 12, 2022 March 23, 2022 9th March Shawn Harris TEXAS ROCKWALL 9th March TEXAS 08-26-2024 Emergency Area Staging Area Landing Area Operational Area Flight Path Landing Area Staging area Emergency Area Blocked Areas Thred Up #5082 801 Industrial Blvd. Grapevine, TX 76051 Date of Lift: 03/12/2022 Time: 8:00AM 32°55’ 47.5”N 97°06’ 16.8”W Thred Up #5082 801 Industrial Blvd. Grapevine, TX 76051 Date of Lift: 03/12/2022 Time: 8:00AM 32°55’ 47.5”N 97°06’ 16.8”W Thred Up #5082 801 Industrial Blvd. Grapevine, TX 76051 Date of Lift: 03/12/2022 Time: 8:00AM 32°55’ 47.5”N 97°06’ 16.8”W Helicopter will not Be more than 125’ Above a 40’ building When air lifting Equipment to the Roof. Pilot will contact: DFW Dallas Fort Worth Airport. Emergency Area Staging Area Landing Area Operational Area Flight Path Landing Area Staging area Emergency Area Blocked Areas Thred Up #5082 801 Industrial Blvd. Grapevine, TX 76051 Date of Lift: 03/12/2022 Time: 8:00AM 32°55’ 47.5”N 97°06’ 16.8”W Thred Up #5082 801 Industrial Blvd. Grapevine, TX 76051 Date of Lift: 03/12/2022 Time: 8:00AM 32°55’ 47.5”N 97°06’ 16.8”W Thred Up #5082 801 Industrial Blvd. Grapevine, TX 76051 Date of Lift: 03/12/2022 Time: 8:00AM 32°55’ 47.5”N 97°06’ 16.8”W Helicopter will not Be more than 125’ Above a 40’ building When air lifting Equipment to the Roof. Pilot will contact: DFW Dallas Fort Worth Airport. Emergency Area Staging Area Landing Area Operational Area Flight Path Landing Area Staging area Emergency Area Blocked Areas Thred Up #5082 801 Industrial Blvd. Grapevine, TX 76051 Date of Lift: 03/12/2022 Time: 8:00AM 32°55’ 47.5”N 97°06’ 16.8”W Thred Up #5082 801 Industrial Blvd. Grapevine, TX 76051 Date of Lift: 03/12/2022 Time: 8:00AM 32°55’ 47.5”N 97°06’ 16.8”W Thred Up #5082 801 Industrial Blvd. Grapevine, TX 76051 Date of Lift: 03/12/2022 Time: 8:00AM 32°55’ 47.5”N 97°06’ 16.8”W Helicopter will not Be more than 125’ Above a 40’ building When air lifting Equipment to the Roof. Pilot will contact: DFW Dallas Fort Worth Airport.