UAV Application
Name
*
First Name
Last Name
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Number
Please enter a valid phone number.
Format: (000) 000-0000.
Work Number
Please enter a valid phone number.
Format: (000) 000-0000.
Cell Number
Please enter a valid phone number.
Format: (000) 000-0000.
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How did you Hear about Air1?
Do you currently have insurance in place for your UAV(s)/other business?
*
Yes
No
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?*
*
Yes
No
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Limit of liability desired
*
$
Other liability
*
$
Medical expense coverage
*
$
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Type
*
Fixed Wing
Rotary Wing
UAV based at
*
Airport/Location
UAV Specifications for Insurance Coverage
*
Rows
Year
Make
Model
Seriel No. Or ID
UAV Value
Control Station Value
Annual Utilization
1
2
3
4
UAV Flight Performance Data
*
Rows
Test Flight Hours
MTOW
Payload Weight
Wing Span
1
2
3
4
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Describe the application/usage of the UAV: (i.e. Photography, Agricultural, Exploration, Transportation, etc.)*
*
Police
Search + Rescue
Photography
Construction / Engineering
Video / Film Production
Pipeline / Powerline Patrol
Thermal Imagery
Employee Training
Mapping
Cargo / Freight Carying
Flight Testing / Demonstrating
Other
Fire
Surveillance
Wildlife Observation
Industrial
Communications
Crop Management
Aerial Marketing
Real Estate Sales
Military (Non-Combat)
Surveying
Atmospheric / Weather Research
Other uses not listed above:
Is the applicant a manufacturer or end user:
*
Primary location the UAV(s) will be operated:
*
Maximum endurance (flight duration) of UAV:
*
Top speed of UAV:
*
Does the UAV have ‘auto-land’ or ‘return-to-home’ capability:
*
Yes
No
If yes to above, is this activated on each flight?
Yes
No
How many UAV units does the applicant own or operate:
*
Is the UAV powered by a gas or electric power plant:
*
Is the UAV designed to deploy / drop payload or other items:
*
How long have the make and model(s) in use been flying:
*
Where will replacement parts and/or spares be purchased:
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Are you operating under the Transport Canada rules and regulations?
*
Yes
No
Is the business solely engaged in UAV operations?
*
Yes
No
Gross revenue
*
Percentage of revenue from UAV operations (%)
*
Have you had any claims related to operating UAVs?*
*
Yes
No
UAV maintenance or repairs provided by:
Is maintenance performed in accordance with manufacturer guidelines?
*
Yes
No
Is a maintenance log book kept?
*
Yes
No
Does applicant own or exclusively lease any other UAV’s?
*
Yes
No
Will anyone other than named pilots operate insureds UAV?
*
Yes
No
Does applicant have any non-owned aircraft or UAV exposure?
*
Yes
No
Has applicant ever had insurance denied or cancelled?
*
Yes
No
Has applicant or named pilot ever had any convictions, or license suspensions?
*
Yes
No
Does the applicant provide training in the operation of UAV’s?
*
Yes
No
If yes to any above questions, provide details below
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Do you have a lien on this UAV?
*
Yes
No
Lien Holder: Name
Lien Holder: Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Lien Amount
$
Loss Payee
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Geographical Area of Operation
*
Operating Body
*
Private (Civil)
Commercial
Government
Military
Other (Describe)
Operating Environment
*
Urban
Rural
Maritime
Outdoor
Industrial
Coastal
Indoor
Near Powerlines
Other
Other (Describe)
Flight Conditions
*
Low Level
Patterned
Night
High Level
IFR Conditions
Line of Sight
Other
Other (Describe)
Number of units in the air at any one time:
*
1
2
Other
Please provide additional information if more than 2:
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Operators
*
Rows
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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of
Pilots are:
*
Employees of the Applicant
Contracted Pilots
Other
Other (Describe)
Pilots have completed formal UAV pilot or operator training
*
Yes
No
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
*
Date
*
-
Month
-
Day
Year
Date
Submit
Submit
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