Drone Sprayer Applicator Program Supplemental Questionnaire
Before getting started, please be prepared to upload or enter key documentation such as your current policy details, VIN(s), and driver’s license(s). Having these ready will help you complete the form more efficiently.
Full Name
*
Drone Business Name
*
Year Business Established
*
ex. 2023
Years of Drone Spraying Experience
*
Email
*
Phone
*
Website
Address
Street Address
City
State
Postal Code
FEIN (if applicable)
*
Do You Have Current Coverage
*
Yes
No
What is the effective date of current coverage?
Please upload current policy documentation:
Click to upload
PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF
Current Coverage Policy Documentation
Coverage of Interest
*
Property
General Liability
Commercial Auto
Workers Compensation
Cyber
*Select at least two options.
Underwriting Information
Describe Your Unmanned Aircraft System
*
Advertising
Agriculture/Farming/Ranching (Non-Spraying)
Chemical/Fertilizer Dealer
Construction
Entertainment
Annual Drone Sales
Drone Service and Repair
Environmental Monitoring
Inspection/Maintenance
Inventory
Mapping/Surveying
Media
Municipal/Educational
Photography/Videography
Real Estate
Security
Seed Dealer
Spraying of Row Crops (Corn, Wheat, Etc...)
Spraying of Orchards/Vineyards
Water Treatment
Other (describe below)
Describe "Other" Unmanned Aircraft System/Drone Operations
Ground Equipment - NOT equipment located on the drone. Example: Extra battery that is recharging. (Check all that apply)
Batteries
Charging Cords
Charging Stations
Computers/Laptops
Cooling Stations
Generators/Inverters
Mixing Stations
Poly Tanks
Remote Controls
RTK Systems
Other (please describe below)
Please describe “Other” Ground Equipment:
Total Estimated Value of All Ground Equipment in Operation:
How Many Auto Power Units Are In Operation? (Number of Vehicles...Excluding Trailers)
Auto Power Units: Permanently Attached Equipment
Comp And Collision
Yes
No
Auto Power Units: Year/Make/Model/VIN# (upload documentation for all that apply)
Click to upload
PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF
How Many Trailers Are In Operation? (Volume of Trailers In Operation):
Trailers: Permanently Attached Equipment
Comp & Collision
Yes
No
Estimated Value Per Trailer (with permanently attached equipment) in Operation:
Please list all trailers and value of each with permanently attached equipment
Trailers: Year/Make/Model/VIN# (upload documentation for all that apply)
Click to upload
PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF
How Many Drivers Will Be Covered Under This Policy?
Please Upload a Valid Driver’s License for Each Driver
Click to upload
PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF
Estimated Annual Employee Payroll
*
Owners Included or Excluded?
*
Included
Excluded
States Where Work Is Performed:
*
Do you have written procedures in place for the operation of the UAS(s)/Drone?
*
Yes
No
Is line of sight maintained with the UAS/Drone at all times during flight?
*
Yes
No
If no, please explain:
Do you keep a copy of the customer information that is collected?
Yes
No
Are the UAS(s)/Drones equipped with return home and GEO-fencing technology?
Yes
No
How many acres do you apply herbicides and pesticides (chemicals) to?
*
What types of crops do you apply herbicides or pesticides to?
How many acres do you apply fertilizer to?
*
What types of crops do you apply fertilizer on?
*
Do you practice the following:
Monitor the wind/guidelines in place:
*
Yes
No
Use Maps:
*
Yes
No
Use GPS:
*
Yes
No
PPE Worn:
*
Yes
No
Formalized Training:
*
Yes
No
Have you ever been named in a lawsuit in regard to your UAS/Drone operations?
*
Yes
No
If yes, please describe the circumstances:
Have you ever reported a claim that resulted in a covered loss?
*
Yes
No
If yes, please provide the loss details including the amount paid for all damages:
How many drones are currently in operation?
*
How would you like to provide your drone information (including VIN, serial number, and current value)? PLEASE IGNORE IF YOU'VE ALREADY UPLOADED YOUR POLICY
*
Upload documentation
Enter details manually
Please upload documentation containing details for all drones in operation, including VIN, serial number, and current value.
Click to upload
PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF
Please input information for ALL drones currently in operation:
Add each additional drone to the next line or separate with a comma
The undersigned is an authorized representative of the applicant and certifies that reasonable inquiry has been made to obtain the answers to questions on this application. He/She certifies that the answers are true, correct and complete to the best of his/her knowledge.
Applicant's First Name
*
Applicant's Last Name
*
Applicant’s Signature:
*
Clear
Date:
*
*Coverage options and program eligibility may vary by state. Certain risks may be ineligible or subject to underwriting approval. Submission of this form does not constitute a complete application. Additional information regarding your business may be requested as part of the underwriting process.