APPLICATION FOR UNMANNED AIRCRAFT SYSTEMS
PRODUCTS LIABILITY INSURANCE

Name of Applicant:
Address:
Your website address:
Form of Business: Corporation Partnership Other (Describe)
List any subsidiary companies, divisions or other entities:
Have any subsidiary companies, divisions or other entities been acquired or divested within the last ten years: Yes No

Insurance is requested from 12:01 A.M. / / to 12:01 A.M. / / (local time at address of applicant)
Coverage	Limits of Liability Desired
Bodily Injury and Property Damage	$	Each Occurrence	$	Annual Aggregate
Grounding Liability	$	Each Occurrence	$	Annual Aggregate
$	Combined Annual Aggregate

Underwriting Information
Product Descriptions (please answer all in as much detail as possible): (a) Describe all your aviation products (the parts or raw materials): (b) Describe the final components/system of which your products are a part and your product’s function and use: (c) Are you responsible for the design of the products or are they manufactured to buyer specifications?: (d) List all models of aircraft of which your products are a part:
2. Applicant has manufactured aviation products for years.
3. Do you own or operate any UAS? Yes No
4. Do you repair or service UAS which are not owed? Yes No
5. Do you lease UAS or other products to others? Yes No If “Yes”, supply a copy of leasing contract.
6. Do you require or strongly recommend that your customers purchase liability insurance for their UAS? Yes No
7. Do you have any exposure for non-owned UAS? Yes No
8. Have you recalled any aviation products during the last five years? Yes No If “Yes”, explain on a separate sheet.
9. Have you discontinued manufacturing any aviation product? Yes No If “Yes”, describe the product and give details as to time of discontinuation, total number of units produced, and amount of past sales for the product, on a separate sheet.
10. Attach copies of: (a) descriptions of contracts where you accept the liability of others and such indemnity provisions;
(b) brochures, specifications or other material describing your product;
(c) your latest annual financial statement; and
(d) warranties you provide.

Distribution
1. Are your products sold on your website? Yes No
2. Are your products distributed by others? Yes No If “Yes”, please list who sells your products.

Disclaimers
1. Are your products sold with a disclaimer statement? Yes No If “Yes”, please provide a copy.
2. Are your products sold with a licensing agreement? Yes No If “Yes”, please provide a copy.

UAS Units Sold and Sales	Last Year 20 (Actual)	Current Year 20 ( Estimated Actual)	Next Year 20 (Estimated)
1. Number of UAS units sold:
2. Total sales of Unmanned Aircraft Systems:	$	$	$
(a) Non-Military UAS Products:
(1) Complete UAS:	$	$	$
(2) Flight component parts of UAS:	$	$	$
(3) Non-flight component parts including controllers:	$	$	$
(b) Military UAS Products:
(1) Complete UAS:	$	$	$
(2) Flight component parts of UAS:	$	$	$
(3) Non-flight component parts including controllers:	$	$	$

Customers List your principal customers and percentages of aviation products sales to each:
Customer	% of Sales	Customer	% of Sales

Loss History and Previous Insurance
1. Have you had any aviation products claims or losses? Yes No If “Yes”, explain on a separate sheet.
2. Has any insurer cancelled, declined or refused to renew any aviation products liability insurance? NOT APPLICABLE IN MO
Yes No If “Yes”, explain on a separate sheet.
3. (a) Name of last or present aviation products liability insurer:
(b) Number of years insured with this aviation products liability insurer: years. Expiration date of policy: / /
4. (a) Name of last or present general liability insurer:
(b) Liability limit of last or present general liability policy: $ Expiration date of policy: / /

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 MINNESOTA

A person who files a claim with intent to defraud, or helps commit a fraud against an insurer, is guilty of a crime.

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.

APPLICABLE IN VERMONT

Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and may be subject to penalties under state law.

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