B Smart - Drone Smart Quote Application Form

Drone Smart Quote Application Form
Broker Information
Broker Name

First NameLast Name
Broker Email
example@example.com
Broker Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Brokerage
Insured Information
Company Name
Insured Name

First NameLast Name
Street Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Format: (000) 000-0000.
Insured Email
example@example.com
Website
Policy Start Date (dd/mm/yy)

YearMonthDay
4 digit year, 2 digit month, 2 digit dayDate
Policy End Date (dd/mm/yy)

YearMonthDay
4 digit year, 2 digit month, 2 digit dayDate

Mandatory

Rows	UAV/eVTOL Make	Model	Value	Units	MTOM (kg) Inc. Payload	# of Units in the Air at Any One Time	Est. Annual Flying Time
1
2
3
4
5
6
7
8
9

Optional

Payloads

Spares / Ground Equipment

Losses/Claims

Privacy & Declaration
Notice To Applicant

All particulars herein are true and complete to the best of my knowledge and no information has been withheld or suppressed and I/we agree that this Application and the terms and conditions of the policy in use by the insurer shall be the basis of any contract between me/us and the Insurer. I hereby authorize this Company to investigate all or any qualifications or statements contained herein.
Signature of Applicant
Authorized representative of applicant must sign.
The Applicant's agent may not sign this Application for the Applicant.
This application does not commit the Company to any liability nor make the Applicant liable for any premium unless the Company agrees to effect this insurance.
Confirm Form is Complete
BOS JotForm Submission Key
BOS JotForm Redirection
Should be Empty:

Drone Smart Quote Application Form