ANCO Insurance: Special Programs - Application for Drone Insurance Coverage

Application for Drone Insurance Coverage

Please Note: It is highly recommended that you read and/or print this form in its entirety and gather materials or information for your responses prior to filling out the form online. Any information you input will be lost if you close your browser or navigate to another page or website prior to submitting your information by pressing the "Submit" button at the bottom of this form.

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General Information
Name of Firm:
Contact Name:
Date Established:
Address:
City:
State:	Zip:
County:
Phone:	Fax:
Branch Office: (Address(es), Phone, Fax)
Email Address:
Website Address:
Firm is:
Federal Employers ID# (FEIN):

Required Underwriting Risk Characteristics for Eligibility:

Maximum flight speed of 60 miles per hour
UAV less than 55 pounds
Operated below 400 feet above ground level
Operated in daylight conditions and only with sight of operator
Location of use is at least 5 nautical miles from nearest airport
Operated within the U.S. and its territories

Any use other than surveying?:

Yes No If "Yes" please specify below:

Underwriting Questions
1.	UAV Information
	Make	Model	Size	Weight	Manufacturer	# in use for this make/model/ manufacturer

2.	Average flying altitude to include maximum altitude?

3.	Area of operation? (City, Town, County, State)

4.	List any airport(s) within 5 miles of operational area:

5.	Does insured want liability only or both liability and hull coverage?
	Liability Only Liability and Hull Coverages
6.	Describe where the UAV's are kept during non-operational use?

7.	Annual hours expected for use?

8.	Please provide pilot record (any pilot ratings and years of experience and where did pilot receive UAV or UAS flight training?)

9.	Is UAV fixed wing, rotor wing, or quad rotor?
	Fixed Wing Rotor Wing Quad Rotor
	Is the UAV Hand launched or self-take off?
	Hand Launched Self-take off
10.	Value of UAV?:
	$
11.	Does UAV come equipped with auto point of take-off return in the event of low battery or lost transmit reception?
	Yes No
12.	Are UAV's ever flown in IFR conditions or at night?
	IFR conditions: Yes No At night: Yes No
13.	Was UAV donated, sold, or loaned by Federal Government?
	Yes No
14.	Total weight of UAV?:

15.	Has the applicant ever had a UAV related loss in past 5 years?
	Yes No
	If so, when and please describe the loss in detail:

16.	Do you need base or additional equipment coverage for the UAV?
	Yes No

Additional Comments

Please give any additional comments you feel appropriate for this quotation. If you have
additional information where there was not enough fields above, please enter them here.

Submission Info
(1) The applicant has read the foregoing and understands that completion of this Application does not bind the Underwriter or the Broker to provide coverage. It is agreed, however, that this Application is complete and correct to the best of applicant's knowledge and belief and that all particulars which may have a bearing upon acceptability as a Professional Liability insurance risk have been revealed. It is understood that this Application shall form the basis of the contract should the Underwriter approve coverage and should the applicant be satisfied with the Underwriters quotation.
Please check box if you agree with the above Statement #1

(2) It is further agreed that, if in the time between submission of this Application and the requested date for coverage to be effective, the applicant becomes aware of any information which would change the answers furnished in response to the "Claims / Liability Issues" section of this Application, such information shall be revealed immediately in writing to the Underwriter.
Please check box if you agree with the above Statement #2

Electronic Signature
(3) I am authorized and agree to use electronic signatures to sign this application. By checking the box below, I agree to transact business using electronic communications, electronic records, and electronic signature rather than paper documents.
Please check box if you agree with the above Statement #3

Your Name:
Your Title:
Date:

Important: Please click on the Print Application button prior to the Submit Form button. You will need to sign the printed copy and then mail it to us. You should also keep a copy of this application for your records to use as a reference for your renewal.

CHECK HERE:

I acknowledge that the information I am providing in this submission is true and accurate to the best of my knowledge.

then

"Endorsed by Texas Society of Professional Surveyors"

Anco Insurance
1111 Briarcrest Drive
Bryan, TX, 77802

979-776-2626
888-275-2626