UAV Hull & Liability Application

UAV Hull & Liability Application
Name*

First Name Last Name
Email*
example@example.com
Address*

Street Address
Street Address Line 2
City Province
Postal Code
Home Number
Please enter a valid phone number.
Work Number
Please enter a valid phone number.
Cell Number
Please enter a valid phone number.

How did you hear about Air1?
Do you currently have insurance in place for your UAV(s)/other business?*

YesNo
Current Broker
If Yes to above question.
Current Underwriter
If Yes to above question.
Has any insurer cancelled or refused to renew your insurance policy in the past 5 years?*

YesNo

Liability Coverage
Single limit bodily injury and property damage liability
Limit of liability desired*
$
Other liability*
$
Medical expense coverage*
$

Physical Damage Coverage
Unmanned Air Vehicle (if multiple UAV or fleet, please provide information in email)
Type*

Fixed WingRotary Wing
UAV based at:*
Airport / Location
.*

Year Make Model Serial No. or ID UAV Value Control Station Value Annual Utilization
1
2
3
4
.*

Test Flight Hours MTOW Payload Weight Wing Span
1
2
3
4

Lien Information
Do you have a lien on this UAV?*

YesNo
Lien Holder: Name
Lien Holder: Address

Street Address
Street Address Line 2
City State / Province
Postal / Zip Code
Lien Amount
$
Loss Payee

Operators
*

Pilot 1 Pilot 2 Pilot 3 Pilot 4
Name
Date of Birth
License
Total UAV Hours
UAV Time Past 12 Months
UAV Time on Model to be Insured
Accidents, Violations, Incidents in Past 5 Years:
Accident Information Upload (If Required)

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Cancelof
Pilots are:*

Employees of the ApplicantContracted PilotsOther
Other (Describe):
Pilots have completed formal UAV pilot or operator training*

YesNo
If yes to above question, please provide details.

Declaration
I declare that the statements and declarations given are true and that no information has been withheld that might influence acceptance of this proposed insurance; and I agree that the statements and declarations given above and signed by me shall be the basis of my contract between myself and Air1 Insurance. This application does not commit the insurer to any liability nor make the applicant liable for any premium unless the insurer agrees in writing that coverage has been bound.
Signature*

Clear
Date*

MonthDay Year
Should be Empty:

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UAV Hull & Liability Application

Liability Coverage

Physical Damage Coverage

Activities Requiring Coverage

Additional Information

Lien Information

Operations

Operators

Declaration

	Pilot 1	Pilot 2	Pilot 3	Pilot 4
Name
Date of Birth
License
Total UAV Hours
UAV Time Past 12 Months
UAV Time on Model to be Insured
Accidents, Violations, Incidents in Past 5 Years:

	Year	Make	Model	Serial No. or ID	UAV Value	Control Station Value	Annual Utilization
1
2
3
4

	Test Flight Hours	MTOW	Payload Weight	Wing Span
1
2
3
4