Fillable UNMANNED AIRCRAFT SYSTEM (UAS) APPLICATION (Colonial General Insurance Agency, Inc)

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UNMANNED AIRCRAFT SYSTEM (UAS) APPLICATION (Colonial General Insurance Agency, Inc)

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UT-APP-442 (12-16) Page 1 of 5
UNMANNED AIRCRAFT SYSTEM (UAS) APPLICATION
Applicant’s Name:
Mailing Address:
Location Address:
Agency Name:
Agent No.:
Address:
E-mail:
Phone No.:
PROPOSED EFFECTIVE DATE: From To 12:01 A.M., Standard Time at the address of the Applicant
ANSWER ALL QUESTIONS—IF THEY DO NOT APPLY, INDICATE “NOT APPLICABLE” (N/A)
Applicant is:
Individual Corporation Partnership Joint Venture Limited Liability Company
Other (Specify):
Website Address:
E-mail Address: Phone No.:
GENERAL INFORMATION
1. Applicant’s Business:
Number of Years in Business:
2. Describe what UAS(s) will be used for:
3. Description of component parts of the unmanned aircraft*:
Year Make and Model Serial Number or ID Specifications Value
* Unmanned Aircraft means the flying portion of the system, either fixed-wing or rotary-wing and flown by a ground
control system, or autonomously through the use of an onboard computer, communication links and any addition-
al equipment that is necessary for the unmanned aircraft to operate safely.
4. Description of the component parts of the unmanned aircraft system support equipment**:
Year Make and Model Serial Number or ID Specifications Value
UT-APP-442 (12-16) Page 2 of 5
** Unmanned aircraft support equipment means control station, data links, telemetry, communication and navigation
equipment necessary to operate the unmanned aircraft. Desktop or laptop computers and cellular phones are not
considered support equipment.
5. Inland Marine Limits of Insurance and Deductible for scheduled UAS(s):
a. Per Item: ............................................................................................................................................... $
b. Per Schedule: ....................................................................................................................................... $
c. Deductible: ........................................................................................................................................... $
6. Are UAS(s) operated in accordance with applicable Federal Aviation guidelines? ........................... Yes No
7. Does applicant have a Certificate of Waiver or authorization from the Federal Aviation
Administration? .........................................................................................................................................
Yes No
8. How many UAS units does applicant own or operate? ........................................................................
9. How many UAS units will be operated at any one time?......................................................................
10. Primary location the UAS(s) will be operated:
11. Will the UAS(s) ever be operated within five miles of an airport? ........................................................ Yes No
If yes, explain:
Names of airport(s):
12. What is the maximum altitude at which each UAS(s) will be operated? ............................................
13. Annual hours each UAS(s) will be operated: .........................................................................................
14. Top speed of UAS(s): ...............................................................................................................................
15. Primary means of control: .............................................................................. Line of Sight Computer Guidance
16. Will UAS(s) be operated outside the operator’s line of sight? .............................................................
Yes No
If yes, explain:
17. Does the UAS(s) have “auto-land” or “return to home” capability? .................................................... Yes No
18. Does applicant own or operate any UAS(s) weighing more than fifty-five (55) pounds? .................. Yes No
If yes, explain:
19. Will UAS(s) be operated within buildings? ............................................................................................. Yes No
If yes, explain:
20. Will UAS(s) be operated within one hundred (100) feet of the public? ................................................ Yes No
If yes, explain:
21. Will UAS(s) be used for the application of chemicals? ......................................................................... Yes No
22. Will UAS(s) be used to carry packages/payloads? ................................................................................
Yes No
23. Name of pilots (Include experience operating this type of equipment):
Pilot Name Experience Flying This Type of Equipment
UT-APP-442 (12-16) Page 3 of 5
24. Does applicant provide any type of training in the operation of a UAS? ............................................ Yes No
25. Does applicant have any Non-Owned UAS exposure? .........................................................................
Yes No
26. Will anyone other than named pilots operate the insured UAS? ......................................................... Yes No
27. Will the aircraft ever be rented or leased to a third party?....................................................................
Yes No
If yes, explain:
ADDITIONAL INFORMATION
28. Prior Carrier Information:
Year: Year: Year:
Carrier
Policy No.
Coverage
Occurrence or Claims Made
Total Premium
29. Loss History—Three Years:
Indicate all claims or losses (regardless of fault and whether or not insured) or occurrences that may give
rise to claims for the prior three years ................................................
Check if no losses in the last three years.
Date of
Loss
Description of Loss
Amount
Paid
Amount
Reserved
Claim Status
(Open or
Closed)
$ $
$ $
$ $
$ $
$ $
$ $
3
0. List any additional information attached with this application:
This application does not bind the applicant nor the Company to complete the insurance, but it is agreed that the infor-
mation contained herein shall be the basis of the contract should a policy be issued.
FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance company or other person files an
application for insurance or statement of claim containing any materially false information or conceals for the purpose of
misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and
subjects such person to criminal and civil penalties. (Not applicable in AL, CO, DC, FL, KS, LA, ME, MD, MN, NE, NY,
OH, OK, OR, RI, TN, VA, VT or WA.)
NOTICE TO ALABAMA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a
loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be
subject to restitution fines or confinement in prison, or any combination thereof.
UT-APP-442 (12-16) Page 4 of 5
NOTICE TO COLORADO APPLICANTS: It is unlawful to knowingly provide false, incomplete, or misleading facts or in-
formation to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may
include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance
company who knowingly provides false, incomplete, or misleading facts or information to a policy holder or claimant for
the purpose of defrauding or attempting to defraud the policy holder or claimant with regard to a settlement or award pay-
able from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory
Agencies.
WARNING TO DISTRICT OF COLUMBIA APPLICANTS: It is a crime to provide false or misleading information to an
insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addi-
tion, an insurer may deny insurance benefits if false information materially related to a claim was provided by the appli-
cant.
NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud, or deceive any insur-
er files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a fel-
ony of the third degree.
NOTICE TO KANSAS APPLICANTS: Any person who, knowingly and with intent to defraud, presents, causes to be pre-
sented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any
agent thereof, any written statement as part of, or in support of, an application for the issuance of, or the rating of an in-
surance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance pol-
icy for commercial or personal insurance which such person knows to contain materially false information concerning any
fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto, commits
a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.
NOTICE TO LOUISIANA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a
loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be sub-
ject to fines and confinement in prison.
NOTICE TO MAINE APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an
insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of
insurance benefits.
NOTICE TO MARYLAND APPLICANTS: Any person who knowingly or willfully presents a false or fraudulent claim for
payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty
of a crime and may be subject to fines and confinement in prison.
NOTICE TO MINNESOTA APPLICANTS: A person who files a claim with intent to defraud or helps commit a fraud
against an insurer is guilty of a crime.
NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he is facilitating a fraud against
an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
NOTICE TO OKLAHOMA APPLICANTS: Any person who knowingly, and with intent to injure, defraud or deceive any
insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading infor-
mation is guilty of a felony.
NOTICE TO RHODE ISLAND APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment
of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be
subject to fines and confinement in prison.
FRAUD WARNING (APPLICABLE IN VERMONT, NEBRASKA AND OREGON): Any person who intentionally presents
a materially false statement in an application for insurance may be guilty of a criminal offense and subject to penalties un-
der state law.
FRAUD WARNING (APPLICABLE IN TENNESSEE, VIRGINIA AND WASHINGTON): It is a crime to knowingly provide
false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penal-
ties include imprisonment, fines, and denial of insurance benefits.
UT-APP-442 (12-16) Page 5 of 5
NEW YORK OTHER THAN AUTOMOBILE FRAUD WARNING: Any person who knowingly and with intent to defraud
any insurance company or other person files an application for insurance or statement of claim containing any materially
false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a
fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars
and the stated value of the claim for each such violation.
APPLICANT’S STATEMENT:
I have read the above application and I declare that to the best of my knowledge and belief all of the foregoing statements
are true, and that these statements are offered as an inducement to us to issue the policy for which I am applying. (Kan-
sas: This does not constitute a warranty.)
APPLICANT’S NAME AND TITLE:
APPLICANT’S SIGNATURE: DATE:
(Must be signed by an active owner, partner or executive officer)
PRODUCER’S SIGNATURE:
DATE:
AGENT NAME: AGENT LICENSE NUMBER:
(Applicable to Florida Agents Only)
IOWA LICENSED AGENT:
(Applicable in Iowa Only)
IMPORTANT NOTICE
As part of our underwriting procedure, a routine inquiry may be made to obtain applicable information concerning
character, general reputation, personal characteristics and mode of living. Upon written request, additional information
as to the nature and scope of the report, if one is made, will be provided.
Agent Email:
Preferred Method of Correspondence Email Fax Mail
Applicant Email:
Preferred Method of Correspondence Email Fax Mail
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UNMANNED AIRCRAFT SYSTEM (UAS) APPLICATION (Colonial General Insurance Agency, Inc)

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Completed 22 August 2020

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