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?
Current Insurer
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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?
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6.
7.
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10.

Third Party Limit of Liability Required:
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Will you be carrying out operations overseas?
Tick that apply:
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Convictions
Have you or ever been convicted of a breach of air navigation safety regulations?
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?
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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Should be Empty:

Recreational UAV Insurance Proposal