APPLICATION FOR

HULL AND LIABILITY INSURANCE

UNMANNED AIRCRAFT SYSTEMS

APPLICANT IS: INDIVIDUAL(S) CORPORATION LLC PARTNERSHIP PUBLIC ENTITY OTHER
NAME OF APPLICANT (Including all affiliated names or Companies):
CONTACT NAME (Who should we talk to if we have any questions):
ADDRESS:
EMAIL ADDRESS:	PHONE NUMBER:	APPLICANT WEBSITE:
INSURANCE IS REQUESTED FROM 12:01 A.M. TO 12:01 A.M. (local time at address of applicant)
NEW INSURANCE POLICY RENEWAL POLICY Name of last aviation insurance carrier (if none, so state):
BUSINESS OR OCCUPATION OF APPLICANT:

Operations

Will the UAS be operated only in the United States of America?	Yes No
Will the UAS be operated in accordance with FAA regulations at all times?	Yes No
Will the UAS be operated indoors?	Yes No
Will the UAS be operated over any persons not directly participating in the operation of the UAS?	Yes No
Do you utilize a Standard Operating Procedure manual?	Yes No If yes please attach
Do you intend to publish by any means data or images that were obtained or created by the operation of any UAS operated by you or on your behalf?	Yes No
Do you have procedures to control the publication of data or images?	Yes No If yes please attach
Please select all intended uses of the UAS:
Agriculture	Construction Support	Educational Research / Development
Energy Infrastructure / Inspection / Support	Events (Concerts / Sports / Weddings etc)	Fire Fighting / Support
Instruction and Training	Mapping / Geophysical	Media / News Gathering
Military	Movie / Film production	Other Commercial Photography / Videography
Package Delivery	Police	Private / Hobby
Property Survey / Inspection / Real Estate	Sales / Demo	Search and Rescue
Surveillance	Wildlife / Conservation
Other. Please describe any other uses:

Insurance & Claims History

Do any of the operators named above have any medical waivers other than corrective lenses or color blindness?	Yes No
In the last 3 years, have any of the operators named above (a) been cited for violation of any FAA regulations, or (b) had their pilot’s or driver’s license suspended or (c) been convicted of driving while intoxicated or (d) of any felony charge?	Yes No
In the last 3 years, have you been involved in any aircraft or UAS accidents or incidents?	Yes No
Please provide the details if you answered “Yes” to any of the above questions.

List all operators of the applicant’s UAS, both employed and contract:

Name	Date of Birth	Pilot Certification	Remote Pilot Airman Certificate	Total UAS Flight Hours	Total UAS Model Flight Hours
Yes No
Yes No
Yes No

If you operate multiple UAS and use multiple operators, please attach the minimum experience and training applicable to each type of UAS flown

Schedule

Equipment that you own or that you rent/lease for more than 30 days

UAS Make and Model Excluding payload/ground equipment	Manufacture Year	Registration / Serial Number	UAS Insured Value	Estimated annual flight hours	Physical Damage Coverage required?
1.	$	Yes No
1.	$	Yes No
1.	$	Yes No

Equipment that you own or that you rent/lease for more than 30 days for which coverage is required

UAS Ground Equipment Make and Model and/or System and Software	Serial Number	Insured Value
1.	$
1.	$
1.	$

UAS Payload Make and Model	Serial Number	Insured Value
1.	$
1.	$
1.	$

Spare Engines and Spare Parts which are owned by you or for which you are legally responsible

Is Physical Damage Coverage to Spare Engines and Spare Parts Required?	Yes No	Total Maximum Insured Value $

Non-Owned Physical Damage Coverage

Do you require insurance for any UAS that you do not own but which you will operate for periods of less than 30 days?	Yes No	Total Maximum Insured Value $
Do you require any insurance for any items of payload that you do not own but which you will be using for periods of less than 30 days?	Yes No	Total Maximum Insured Value $

War, hi-jacking and other perils Physical Damage Coverage

This affords insurance for physical damage arising from, occasioned by or in consequence of war, hi-jacking and other perils such as malicious damage, sabotage or any unlawful seizure or wrongful exercise of control of the aircraft.	Is War Physical Damage Coverage required?	Yes No

Liability Coverage

LIMITS OF INSURANCE	EACH OCCURRENCE LIMIT
Single Limit Bodily Injury and Property Damage Liability: Also includes Liability arising from: occasioned by or in consequence of war hi-jacking and other perils the operation of UAS you rent/lease/borrow for periods of less than 30 days UAS operated on your behalf by others	$
Personal Injury Liability:	$

Acts of Terrorism under the TRIPRA

Coverage for Acts of Terrorism under the Terrorism Risk Insurance Program Reauthorization Act of 2007 and 2015 (TRIPRA). Coverage provided for bodily injury and property damage for which you may be liable for certified acts of terrorism.	This coverage is automatically quoted if the below box is left unchecked I wish to decline TRIPRA coverage.

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 If so, explain circumstances:

FRAUD STATEMENTS

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects that person to criminal and civil penalties (In Oregon, the aforementioned actions may constitute a fraudulent insurance act which may be a crime and may subject the person to penalties). (In New York, the civil penalty is not to exceed five thousand dollars ($5,000) and the stated value of the claim for each such violation). (Not applicable in AL, AR, AZ, CO, DC, FL, KS, LA, ME, MD, MN, NM, OK, PR, RI, TN, VA, VT, WA and WV).

APPLICABLE IN AL, AR, AZ, DC, LA, MD, NM, RI and WV

Any person who knowingly (or willfully in MD) presents a false or fraudulent claim for payment of a loss or benefit or who knowingly (or willfully in MD) presents false information in an application for insurance is guilty of a crime and may be subject to fines or confinement in prison.

APPLICABLE IN COLORADO

It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the department of regulatory agencies.

APPLICABLE IN FLORIDA and OKLAHOMA

Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony (In FL, a person is guilty of a felony of the third degree).

APPLICABLE IN KANSAS

Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written statement as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act.

APPLICABLE IN MAINE, TENNESSEE, VIRGINIA and WASHINGTON

It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.

APPLICABLE IN PUERTO RICO

Any person who knowingly and with the intention of defrauding presents false information in an insurance application, or presents, helps, or causes the presentation of a fraudulent claim for the payment of a loss or any other benefit, or presents more than one claim for the same damage or loss, shall incur a felony and, upon conviction, shall be sanctioned for each violation by a fine of not less than five thousand dollars ($5,000) and not more than ten thousand dollars ($10,000), or a fixed term of imprisonment for three (3) years, or both penalties. Should aggravating circumstances be present, the penalty thus established may be increased to a maximum of five(5) years, if extenuating circumstances are present, it may be reduced to a minimum of two (2) years.

All particulars herein are declared to be true and complete to the best of my/our knowledge and no information has been withheld or suppressed and I/we agree that this application and the terms and conditions of the policy in use by the insurer shall be the basis of any contract between me/us and the insurer. I hereby authorize the insurer to investigate all or any qualifications or statements contained herein. Date ___________________________ Applicant’s Signature(s) ____________________________________________________________________
THIS APPLICATION DOES NOT COMMIT THE INSURER TO ANY LIABILITY NOR MAKE THE APPLICANT LIABLE FOR ANY PREMIUM UNLESS AND UNTIL THE INSURER AGREES TO EFFECT THIS INSURANCE.

THE INSURANCE PRODUCER COMPLETES THE BELOW SECTION.

Name of Insurance Producer:
State License Number:	License State:
Address:
For how long have you been designated this applicant’s Broker of Record?