UAV Insurance Application

UAV OPERATOR INSURANCE APPLICATION
Click here for Insurance Terms & Definitions.
APPLICANT INFORMATION
How did you hear about us?*
Select how you found our website.
Insured Name*
The name of your production company or entity (or individual name if not incorporated) you would like to insure. Use the same name as on your rental quote.
Entity Type*
Full Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
E-mail*

Confirmation Email
Website
Description of your operations:*
Date Established*

MonthDayYear
Date
FAA 333 Exemption Number:*
UAV Usage:*

Commercial UseGovernment UseRecreational Use

UAVs and Equipment List*

Maximum number of UAVs in flight at one time:*
Total Estimated annual flight hours for operation:*
Any UAVs with Maximum take off mass greater than 20kg, including payload?*

YesNo

Ground Control Station (GCS) and ancillary equipment (if applicable):

COVERAGE REQUIRED
Third Party Liability Limit:*

$1,000,000$2,000,000$3,000,000$5,000,000
Physical loss & damage to UAV*
Covers physical loss or damage to UAV (airframe, payload, launch station and/or GCS)
General Liability

Covers liability to third parties for third party loss/damage, not consequential of UAV failure, but on site and in relation to the Insured’s UAV activities.
Do you require $1,000,000 coverage?*

YesNo
Please provide company turnover:*

Pilot Information

	Pilot 1	Pilot 2	Pilot 3	Pilot 4	Pilot 5
Name:
Date of Birth:
License:
Total time on UAV:
UAV time past 12 months:
UAV time on model to be insured:
Accident/Incidents in the past 5 years:

Personal Accident Coverage

Provides benefits in accordance with the following: Death, Loss of one limb, Loss of two or more limbs, Loss of sight of one eye, Loss of sight of both eyes, Loss of sight of one eye, and loss of one limb.
Number of Pilots to be covered:
Salaries of pilots to be covered:
Sum insured required:

Additional Information, Comments
Additional Information or Comments, if necessary, can be provided.
Would you like to receive our quarterly newsletter?*

YesNo
NY License # BR-1001302

CA License # 0I36156 - dba in CA as New York Film Emporium Insurance Services
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UAV OPERATOR INSURANCE APPLICATION