Member Information (* is required)

Member name *

Your name *

Member number

Email *

Choose one *

Addition to policy
Deletion from policy

Desired limit of liability (choose one): *

$500,000 Liability ($400 annual)
$1,000,000 Liability ($750 annual)

Drone 1 Information

Year *

Make *

Model *

Size *

Weight *

Registration # *

Manufacturer Serial # *

Vehicle Type *

Fixed Wing
Rotor
Underwater ROV

Annual Hours of Operation *

Value *

Drone 1 Purpose and Use

Describe Purpose and Use *

Drone 1 Pilot Details

Operator/Pilot Name *

Training/Relevant Experience *

Add Additional Drone Policy Changes?

Yes
No

Add/delete additional drone(s)

Additional Drones How many Drones would you like to add/delete?

0 1 2 3 4 5

Drone 2

Policy Type Drone 2 *

Addition to policy
Deletion from policy

Desired limit of liability (Drone 2): *

$500,000 Liability ($400 annual)
$1,000,000 Liability ($750 annual)

Year Drone 2 *

Make Drone 2 *

Model Drone 2 *

Size Drone 2 *

Weight Drone 2 *

Registration # Drone 2 *

Manufacturer Serial # Drone 2 *

Fixed or Rotor Wing Drone 2 *

Fixed Wing
Rotor

Annual Hours of Operation Drone 2 *

Value Drone 2 *

Drone 2 Purpose and Use

Purpose and Use Drone 2 *

Drone 2 Pilot Details

Operator/Pilot Name Drone 2 *

Training/Relevant Experience Drone 2 *

Drone 3

Policy Type Drone 3 *

Addition to policy
Deletion from policy

Desired limit of liability (Drone 3): *

$500,000 Liability ($400 annual)
$1,000,000 Liability ($750 annual)

Year Drone 3 *

Make Drone 3 *

Model Drone 3 *

Size Drone 3 *

Weight Drone 3 *

Registration # Drone 3 *

Manufacturer Serial # Drone 3 *

Fixed or Rotor Wing Drone 3 *

Fixed Wing
Rotor

Annual Hours of Operation Drone 3 *

Value Drone 3 *

Drone 3 Purpose and Use

Purpose and Use Drone 3 *

Drone 3 Pilot Details

Operator/Pilot Name Drone 3 *

Training/Relevant Experience Drone 3 *

Drone 4

Policy Type Drone 4 *

Addition to policy
Deletion from policy

Desired limit of liability (Drone 4): *

$500,000 Liability ($400 annual)
$1,000,000 Laibility ($750 annual)

Year Drone 4 *

Make Drone 4 *

Model Drone 4 *

Size Drone 4 *

Weight Drone 4 *

Registration # Drone 4 *

Manufacturer Serial # Drone 4 *

Fixed or Rotor Wing Drone 4 *

Fixed Wing
Rotor

Annual Hours of Operation Drone 4 *

Value Drone 4 *

Drone 4 Purpose and Use

Purpose and Use Drone 4 *

Drone 4 Pilot Details

Operator/Pilot Name Drone 4 *

Training/Relevant Experience Drone 4 *

Additional notes use for extra details, special requests, or if a specific effective date is desired:

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