About You / Your BusinessLegal Business Name* Legal Entity:*IndividualLLCCorporationPartnershipOtherPrimary Address:* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone:*Email:* Key Contact Name:* First Last Years of Industry Experience:*Description of Operations:* Do you have your Part 107 certification?:* Yes No Will the aircraft(s) be managed by other parties?:* Yes No Have you had any accidents, incidents, or claims in the past 5 years?:* Yes No Has your insurance ever been cancelled or non-renewed?:* Yes No CoverageCoverage Start Date:* MM slash DD slash YYYY What limit of liability coverage are looking for? ($1mil is standard):*Excluded$1mil / $1mil$1mil / $2mil$2mil / $2mil$3mil / $3mil$4mil / $4mil$5mil / $5milDo you need hull coverage (physical damage coverage)?:* Yes No About Your Drone(s)How Many Drones Do You Need Covered?:*If over 4, please contact us directlySelect1234Drone #1 Make:* Drone #1 Model:* Drone #1 Year:* Drone #1 Serial Number:* Drone #2 Make:* Drone #2 Model:* Drone #2 Year:* Drone #2 Serial Number:* Drone #3 Make:* Drone #3 Model:* Drone #3 Year:* Drone #3 Serial Number:* Drone #4 Make:* Drone #4 Model:* Drone #4 Year:* Drone #4 Serial Number:* About Your Payload (i.e. Camera)How Many Payloads Do You Need Covered?:*If over 4, please contact us directlySelect1234Payload #1 Make:* Payload #1 Model:* Payload #1 Year:* Payload #1 Serial Number:* Payload #2 Make:* Payload #2 Model:* Payload #2 Year:* Payload #2 Serial Number:* Payload #3 Make:* Payload #3 Model:* Payload #3 Year:* Payload #3 Serial Number:* Payload #4 Make:* Payload #4 Model:* Payload #4 Year:* Payload #4 Serial Number:* About Your Gimbal(s)How Many Gimbals Do You Need Covered?:*If over 4, please contact us directlySelect1234Payload #1 Make:* Payload #1 Model:* Payload #1 Year:* Payload #1 Serial Number:* Payload #2 Make:* Payload #2 Model:* Payload #2 Year:* Payload #2 Serial Number:* Payload #3 Make:* Payload #3 Model:* Payload #3 Year:* Payload #3 Serial Number:* Payload #4 Make:* Payload #4 Model:* Payload #4 Year:* Payload #4 Serial Number:* Operation & UsagePrimary Location the UAV(s) will be operated?:* Annual hours each UAV(s) will be operated?:*Maximum endurance (flight duration) of UAV?:*Primary means of control?:* How long have you been flying UAV(s)?:*Are any of your UAV(s) designed to deploy or drop items?:* Yes No Do any of your UAV(s) have an "auto-land" and "return home" capability?:* Yes No Will the UAV(s) be operated over water?:* Yes No Do you have a Formal Safety Program and Procedure?:* Yes No Will aircraft be rented or leased to a third party?:* Yes No Do you intend to publish by any means data or images?:* Yes No Describe intended use of UAV(s):* Preferred Broker*Select BrokerAlec RobertsNick PurselDanny ElisevichPete GybenJohn HartDaniel BanElizabeth BellNo PreferenceHow did you hear about us?:* Google Referral Yelp Other Who referred you?:* How?: CAPTCHA
