NZ Commercial UAV Insurance Form

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Date

MonthDayYear
Date
Commercial UAV Insurance Proposal
Applicants Name

First NameLast Name
Email
example@example.com
Phone Number
Name of Insured
Address

Street Address

Street Address Line 2

CityState

Postal CodeCountry
Are you GST registered?
GST Number
Insurance Start Date

DayMonthYear
Date
Do you currently have an insurance provider?
Current Insurer
Business or Occupation
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UAOC Verification
Does your company hold (or will hold by the time you commence operations) a valid Unmanned Aircraft Operator Certificate?
Upload your UAOC (Unmanned Aircraft Operator Certificate)

Cancelof
Please list the privileges will you be utilising outside of the Part 101 rules as per your company Exposition (e.g., BVLOS, night operations unshielded, operations of aircraft greater than 25kg, etc.)
Upload your company Operations Specifications (Ops Specs)

Cancelof
Will your pilots be operating under another company’s Unmanned Aircraft Operator Certificate?
Upload the UAOC of the company your pilots will be operating under

Cancelof
Please list the privileges will you be utilising outside of the Part 101 rules as per the company Exposition your pilots will be operating under (e.g., BVLOS, night operations unshielded, operations of aircraft greater than 25kg, etc.)
Upload the company Operations Specifications (Ops Specs) your pilots will be operating under

Cancelof
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RPAS Register

Rows	Make/Model	Serial Number	Maximum Take Off Weight (kg)	Value NZD(Excluding GST)	Estimated Hours of Operation in the Next 12 Months?	Tethered or Non-Tethered?
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Will any of these RPAS be operated beyond visual line of sight (BVLOS)?
Maximum number of RPAS in the air at any one time?
Third Party Limit of Liability Required:

Other
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Equipment/Payload Register

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Pilot Register

Rows	Name	Total UAV Flight Time (Hrs) Please specify the RPAS type(s) and model(s) flown:	Licenses/Qualifications
1.
2.
3.
4.
5.
6.
7.

Upload Pilot Licenses/Qualifications

Cancelof
Will you be carrying out operations overseas?
Tick that apply:
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Convictions
Have you or any of the above operators been convicted of a breach of air navigation safety regulations?
If yes, please provide details.
Has any operator named above been convicted of driving a motor vehicle under the influence of drugs or alcohol during the last 5 years?
If yes, please provide details.
Has any operator named above ever had their license suspended or cancelled?
If yes, please provide details.
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Previous Insurance
Have you (or a corporation of which you were a director or, if the proposer is a corporation, a person who is a director of the proposer) previously held an aircraft or RPAS insurance policy?
Insurer Name
Policy Number
Has any insurer cancelled, declined or refused to renew any such insurance policy?
Please provide details.
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By submitting this form...

You agree that we may use the information provided to contact you regarding your quote. We may reach out to you via phone, email, or other means to provide further assistance. Your submission indicates your consent for us to store and process your information for the purpose of providing the requested quote and related services.
Applicants Name
Date

MonthDayYear
Date
Applicants Signature

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Commercial UAV Insurance Proposal