Drone Insurance Application Form

Drone Insurance Application Form
Personal Information
Name
First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Date of Birth
MonthDayYear
Date
Occupation
Gender
Other
Drone Information
Make
Model
Serial Number
Date of Purchase
MonthDayYear
Date
Current Value $
Purpose of Use
Other
Maximum Altitude
Maximum Flight Distance
Does the drone have any modifications or aftermarket additions? (If yes, please provide details)
Please select the coverage options you are interested in
Have you had any accidents or incidents with this drone in the past?
Please provide details
Have you received any training or certification for operating drones?
Please provide details
Are you aware of any regulations or restrictions regarding drone operations in your area?
Please specify
Declaration:
I declare that the information provided above is true and complete to the best of my knowledge. I understand that any misrepresentation or omission may result in the voiding of my insurance coverage.
Date
MonthDayYear
Date
Signature
Clear
Should be Empty:

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Personal Information