Application Form - Unmanned Aerial Vehicle
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1
2Allianz Global Corporate & Specialty
Unmanned Aerial Vehicle
Allianz Global Risks US Insurance Company
130 Adelaide Street West Suite 1600
Toronto, ON M5H 3P5
Application Form
Fax 416-849-4555
APPLICANT DETAILS
Name of Insured:
Street Address:
City:
Province:
Postal Code:
Current Insurer:
Expiry date:
Has prior insurance ever been Cancelled or Non-Renewed?
PRINCIPAL
Owner:
UAV INFORMATION
Serial No.
Fixed Wing /
Annual
Year
Make & Model
Max Weight
Insured Value
Liability Limit
or ID
Rotary Wing
Utilization
UAV USE (please detail):
UAV BASE / LOCATION:
LIENHOLDERS a/o LOSS PAYEES:
OPERATING ENVIRONMENT
FLIGHT CONDITIONS
Urban
Low-Level
Rural
High-Level
Coastal
Patterned
Industrial
Line of Sight
Indoor
Night
Outdoor
IFR conditions
Other, describe:
Other, describe:
Is the Applicant a Manufacturer or End User:
Primary location the UAV(s) will be operated:
Maximum Endurance (flight duration) of UAV:
Top Speed of UAV:
Does the UAV have ‘auto-land’ or ‘return-to-home’ capability:
How many UAV units does the Applicant own or operate:
Is the UAV powered by a gas or electric power plant:
Is the UAV designed to deploy / drop payload or other items:
How long have the make and model(s) in use been flying:
Where will replacement parts and/or spares be purchased:
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Parent category: Business