Heffernan Insurance Brokers

Aviation Insurance Request Form

Please complete the form below, and one of our team members will reach out to discuss your aviation insurance needs.

Sorry, we are unable to assist if the UAV is used only for pleasure. The insurance company will quote only if there is some business use.

Policyholder's Information

If the UAV will be owned & operated by a Corporation, LLC or DBA enter that name below. If it will be owned and operated by an individual(s) reflect those names below.
Name(s)*

Is this a
CorporationLLCDBAIndividual

Occupation

Street Address

Contact Information for Person Handling Insurance

What is the address (URL) of your website?

How did you hear about us?

Is this a new purchase?
YesNo

If not provide current insurance company data (if any) below:
Present Insurance Company (not broker)

Policy Expiration Date

Aircraft Data

UAV/Drone #1

Year Built

Make/Model/Include model number i.e. DJI Phantom 2 Vision Plus

Who manufactured the aircraft?

Aircraft Data

UAV/Drone #2 (if applicable)

Year Built

Make/Model/Include model number i.e. DJI Phantom 2 Vision Plus

***List additional UAVs to be quoted in the Comments section at the bottom of this survey. Be sure to give the year, make, and model.
Who manufactured the aircraft?

Proposed Use of Aircraft
Business. I.e. Real Estate Aerial Photography. No charge to others.Commercial. A charge will be made to others for the operation of the aircraft.Pleasure. No business or commercial uses at all. Just pleasure flying.

Will the aircraft be flown “line of sight” only?
YesNo

Describe intended business use of the aircraft in detail:

Area of Operations

In what states will the aircraft generally be operated?

Will the aircraft be operated in other countries? If yes, please list.

Insurance desired

$500,000 Combined Single Limit of bodily and property damage$1,000,000 Combined Single Limit of bodily and property damageOther (please list):

During the last 3 years have you had any aviation accidents or FAR violations?
If yes, please provide details.

Pilots/Operators

Comments
Please list the year, make, & model of any additional UAVs to be quoted as well as any questions or comments below:

Thank you for taking the time to complete this form.