NZ Recreational Insurance Form

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Date

MonthDayYear
FormDate
Recreational 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
Insurance Start Date*

DayMonthYear
Date
Do you currently have an insurance provider?*

YesNo
Current Insurer*
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RPAS Register*

	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.

Third Party Limit of Liability Required:*

$10,000,000
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Will you be carrying out operations overseas?*

YesNo
Tick that apply:*

AustraliaPacific Islands
💾 Note: You can save your progress at any time. A resume link will be sent to your inbox so you can continue later.

💾 Note: You can save your progress at any time. A resume link will be sent to your inbox so you can continue later.

Convictions
Have you or ever been convicted of a breach of air navigation safety regulations?*

YesNo
If yes, please provide details.*
Have you been convicted of driving a motor vehicle under the influence of drugs or alcohol during the last 5 years?*

YesNo
If yes, 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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Recreational UAV Insurance Proposal