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Application
Coverage Detail
UAV/UAS (Drone) Insurance Policy Application
Unmanned Aircraft Hull & Liability Coverages (L.o.S. Operations, <400 ft. alt.)
Applicant
Entity:
Individual
Corporation
LLC
Partnership
Other
Full Name:
Business / Occupation:
Phone Number:
Email Address:
Street Address:
City:
State:
--- Please Select a State ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
Washington DC
West Virginia
Wisconsin
Wyoming
Zip Code:
UAS / UAV
Year:
Make:
Model:
Registration / Serial Number:
Purchased by Applicant:
New
Used
Design:
Prototype
Production
Wings:
Fixed
Rotor
Propulsion:
Single-engine
Multi-engine
Battery
Other
Total Hours Flown Since Manufacture:
Annual Flight Hours (Estimate):
General Use of the UAS:
Wingspan (in Feet):
Maximum Takeoff Weight (in Pounds):
Maximum Range:
Maximum Altitude:
Maximum Endurance:
Is the UAS exempt from FAA 333?:
Yes
No
Will the UAS operate under an FAA-approved COA?:
Yes
No
Will the UAS only be flown by licensed pilot(s)?:
Yes
No
How many UAS can be operated from a single GCS?:
Operating Entity:
Civil
Government
Military (non-combat)
Operating environments (Sum should be 100%):
% Urban
% Semi-urban
% Industrial
% Rural
% Over Water
% Over Desert
Sum:
0
%
Flight Conditions:
Night
IFR
Low-level
Operations over public events?:
Yes
No
Please describe the operations over public events:
Describe the following as applicable to this UAV / UAS
Take-off Procedure:
Landing Procedure:
Auto-pilot Capabilities:
Primary Communication with UAS:
Levels of Data-link Redundancy:
Loss-link Procedure:
Obstacle / Aircraft Sensing and Avoidance Capabilities:
Protections Against Third-party Communications:
On-board Jamming / Anti-spoofing Hardware:
On-board Backup Power Supply:
Emergency Parachute System:
Geographic Area(s) of Operation:
Payload
Hazardous Materials or Components?:
Yes
No
Please describe their function:
Ground Control System
Year:
Make:
Model:
Registration / Serial Number:
Purchased by Applicant:
New
Used
Systems and Software:
Security
UAS/UAV
Storage Location(s):
Security (including locks, alarms, personnel, etc.):
Ground Equipment
Storage Location(s):
Security (including locks, alarms, personnel, etc.):
Payload
Storage Location(s):
Security (including locks, alarms, personnel, etc.):
Maintenance
Does the UAS undergo routine maintenance and testing in accordance with the manufacturer's guidelines?:
Yes
No
Maintenance Performed By:
Applicant
Third-party
Other
Full Name of Maintenance Supervisor:
Number of years in this position:
Company:
Pilots
Full Name of Chief Pilot:
Relationship to Applicant:
Employee
Contractor
Other
Number of years piloting for applicant:
Description of flight training program:
Description of recurrent flight training curriculum:
Pilots who operate the Applicant's UAS
Chief Pilot
Full Name:
Relationship to Applicant:
Employee
Contractor
Employer:
Is the pilot exempt from FAA 333?:
Yes
No
Types of Aircraft/UAS Flown:
Training/Relevant Experience:
Pilot 2
Full Name:
Relationship to Applicant:
Employee
Contractor
Employer:
Is the pilot exempt from FAA 333?:
Yes
No
Types of Aircraft/UAS Flown:
Training/Relevant Experience:
Pilot 3
Full Name:
Relationship to Applicant:
Employee
Contractor
Employer:
Is the pilot exempt from FAA 333?:
Yes
No
Types of Aircraft/UAS Flown:
Training/Relevant Experience:
Pilot 4
Full Name:
Relationship to Applicant:
Employee
Contractor
Employer:
Is the pilot exempt from FAA 333?:
Yes
No
Types of Aircraft/UAS Flown:
Training/Relevant Experience:
Non-owned Aircraft
Do any employees (including pilots employed by the applicant) pilot UAS not owned by the applicant or the applicant's business?:
Yes
No
Describe usage:
Lienholder
Applicant is:
Sole owner
Owner subject to lien
Lesee
Has a lien been granted for the UAS?:
Yes
No
Amount of Encumbrance (excluding interest and finance charges):
Will Breach of Warranty Coverage be required by the lienholder?:
Yes
No
Full Name of Lienholder:
Street Address:
City:
State:
--- Please Select a State ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
Washington DC
West Virginia
Wisconsin
Wyoming
Zip Code:
Are engines, spare engines, or other aircraft equipment subject to separate lien or mortgage?:
Yes
No
Describe:
Insurance History
Has this UAS previously been covered by aviation insurance?:
Yes
No
Name of most recent insurance carrier:
To the applicant's knowledge, has any damage been sustained by, or have any claims been made by others that have arisen out of the operation of,
any aircraft or UAS
owned by or in the custody of the applicant?:
Yes
No
Describe:
Has any insurance company or underwriter at any time declined an application submitted by, or canceled or refused to renew a policy held by, the applicant or any of the pilots named herein with regard to any type of insurance? (Not applicable in MO):
Yes
No
Explain the circumstances:
UAS / UAV / Aircraft Claims History
Claim 1
Date of Occurrence:
Amount Paid:
Description of Loss:
Claim 2
Date of Occurrence:
Amount Paid:
Description of Loss:
Claim 3
Date of Occurrence:
Amount Paid:
Description of Loss:
Requested Insurance
Liability Coverage
Liability Coverage 1
Description:
Requested Limits (per occurrence):
Liability Coverage 2
Description:
Requested Limits (per occurrence):
Liability Coverage 3
Description:
Requested Limits (per occurrence):
Hull Coverage
UAS/UAV
Insured Value:
Physical Damage Coverage:
Yes
No
War Risk Coverage:
Yes
No
Ground Equipment
Insured Value:
Physical Damage Coverage:
Yes
No
War Risk Coverage:
Yes
No
Payload
Insured Value:
Physical Damage Coverage:
Yes
No
War Risk Coverage:
Yes
No
Insurance Effective Date
As Soon As Possible
Specific
