Drone/UAV Insurance Application

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Organization Type*
Organization Name*
Name*
First Last
Phone*
Email*
Address*
Street Address Address Line 2 City State ZIP Code

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Will the UAV/UAS be used outside of the continental United States*
- Yes
- No
Is UAV/UAS 55lbs or greater*
- Yes
- No
Will the UAV/UAS be used for chemical spraying*
- Yes
- No
Will the UAV/UAS be used to deploy or drop objects*
- Yes
- No
Will the UAV/UAS be used above 400 feet(agl)*
- Yes
- No
Will the UAV/UAS be used within 5 miles of an airport*
- Yes
- No

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Intended Use*
- Inspection
- Aerial Photography/Filming
- Agriculture
- Mapping
- Surveying
- Real Estate
- Hobby

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Drone Information*
Add additional items by clicking plus button (+) to the right.
Year Make Model Serial Number Hull Coverage (Yes/No) Drone Value

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Payload Information
Skip this page if you selected NO for Hull Coverage.
Description of Payload Value Serial Number

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Operators*
First Name Last Name UAV Hours Flown
Will all operators listed above hold either (a) Remote Pilot Airman Certificate (Part 107) or (b) 333 FAA Exemption?
- Yes
- No

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Does the Applicant own or exclusively lease any other aircraft?*
- Yes
- No
If yes, please explain ownership/lease of other aircraft
Have you completed a formal ground and flight school (Include FAA Ground School)?*
- Yes
- No
Do you maintain a Build Log and Maintenance Log?*
- Yes
- No
Do you maintain a Flight Log?*
- Yes
- No
Does the UAV/UAS have an iOSD and recordable flight log?*
- Yes
- No
Does the UAV/UAS have a remotely recordable flight log?*
- Yes
- No
Will the UAV/UAS be operated over water?*
- Yes
- No
If yes, how often?
Average number of flights over water per year:
Will the UAV/UAS ever be rented or leased to a third party?*
- Yes
- No
Do you have a formal safety program and procedure in place?*
- Yes
- No

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Feel free to email us to ask questions, or just to say hello!

info@insuremydrone.net

213-634-2550

Disclaimer:

Pricing posted on website are estimates and subject to change upon underwriting review.
The information provided is only a snapshot of the coverage available to you.
Please refer to your policy documents for specific coverage information.

Year	Make	Model	Serial Number	Hull Coverage (Yes/No)	Drone Value

Description of Payload	Value	Serial Number

First Name	Last Name	UAV Hours Flown