Name: Intermarket Insurance Agency
Address: 205 East Main St, Huntington, NY, 11743, US
Telephone: (631) 421-2424

1. GENERAL INFORMATION
Name
First Last
Address
Street Address Address Line 2 City State ZIP Code
Home Phone
Work Phone
Current Insurance Carrier
Current Coverage Expires
MM slash DD slash YYYY
Check all that apply below
- Applicant is an Individual
- Applicant is a Corporation
- Third Choice
- Applicant is a Partnership* (explain below)
- Applicant is Other* (explain below)
- Aircraft will be operated under FAR Part 135
- Aircraft will be managed by other party (not Applicant)
- No Accidents/Incidents or Claims in last 5-years
- Insurance has never been Canceled or Non-Renewed
*Use this space provided to name each partner or the entity that best describes the applicant (which ever applies)
2. UAV INFORMATION
Serial Number or ID Year Make & Model and Flight Controller Specifications Insured Value Liability Limit
PAYLOAD INFORMATION
Serial Number or ID Year Make & Model Specifications Insured Value Comments
GIMBAL INFORMATION
Serial Number or ID Year Make & Model Specifications Insured Value Comments
a. Is the Applicant a Manufacturer or End User:
b. Primary location the UAV(s) will be operated (test site, military base, etc)
c. Annual hours each UAV(s) will be operated
d. Maximum Endurance (flight duration) of UAV
e. Top Speed of UAV
f. Primary means of control – line of sight or computer guided
g. Does the UAV(s) have “auto-land” or “return to home” capability
h. How many UAV units does applicant own or operate
i. How many UAV units will be operated at any one time
j. Is the UAV powered by a gas or electric power plant
k. Is the aircraft designed to deploy/drop payload or other items
l. How long have the make & model (s) operated been flying
List names and addresses of loss payees and lienholders
5. AIRCRAFT USE INFORMATION
SN or ID
- Sales and Demo
- Aerial Photo/Survey
- Public Safety
Est. Annual Hrs
SN or ID
- Sales and Demo
- Aerial Photo/Survey
- Public Safety
Est. Annual Hrs
SN or ID
- Sales and Demo
- Aerial Photo/Survey
- Public Safety
Est. Annual Hrs
SN or ID
- Sales and Demo
- Aerial Photo/Survey
- Public Safety
Est. Annual Hrs
SN or ID
- Sales and Demo
- Aerial Photo/Survey
- Public Safety
Est. Annual Hrs
6. NAMED PILOTS (Include Time Operating Types of Equipment Insured)
Pilot Name
Pilots are:
- Employees of the Applicant
- Contract Pilots
- Other
Pilot(s) have completed their FAA Part 107 Small UAS Rating?
- Yes
- No
7. ADDITIONAL INFORMATION
Does Applicant currently hold an FAA Certificate of Authorization (COA)? (if applicable)
If an FAA Certificate of Authorization (COA) has been issued, what was the basis for issuance:
Aircraft Maintenance provided by:
Will insured aircraft be used outside the continental United States?
- Yes
- No
Does Applicant own or exclusively lease any other aircraft?
- Yes
- No
Will anyone other than named pilots operate the insured aircraft?
- Yes
- No
Does Applicant have any Non-Owned Aircraft or UAV exposure?
- Yes
- No
Has Applicant ever had insurance denied or cancelled?
- Yes
- No
Has Applicant or Named Pilot ever had any incidents, accidents, or violations?
- Yes
- No
Has Applicant or Named Pilot ever had any felony convictions or license suspensions?
- Yes
- No
Does the applicant provide training in the operation of UAV’s?
- Yes
- No
Explain all YES answers
5-YEAR LOSS HISTORY (attach loss runs if available)
Have you completed a formal ground and flight school (Include FAA Ground School)?
Do you maintain a Build Log and Maintenance Log?
Do you maintain a Flight Log?
Does the aircraft have an iOSD and recordable flight log?
Does the aircraft have a remotely recordable flight log?
If so, how often (average number of flights per year)?
Will the aircraft ever be rented or leased to a third party?
Do you have a formal safety program and procedure in place?

Serial Number or ID	Year	Make & Model and Flight Controller	Specifications	Insured Value	Liability Limit

Serial Number or ID	Year	Make & Model	Specifications	Insured Value	Comments

UAV Insurance Application