Risk questionnaire for drones

Transcrição

www.drohnenversicherung.eu
Risk questionnaire for drones
1. General Information
Name, first name or company
_________________________________________________________________________________________
Street, No.
_________________________________________________________________________________________
Postcode, Town / City
_________________________________________________________________________________________
Tel:
Fax:
_________________________________________________________________________________________
eMail:
Homepage:
_________________________________________________________________________________________
Current Insurer:
Type:
Insurer:
expiry date:
Terminated:
Third Liability
__________________________________________________________________________________________
Kasko
Electronics
2. Third Liability Insurance
I / we require the following insurance coverage for 12 months: __________________________________
(Offer valid for one drone – in Europe incl. Canary Islands and neighboring Mediterranean countries)
Premium plus. VAT 19%.
Holder liability insurance
☐ EUR 1.000.000
EUR 121,50
☐ EUR 2.000.000
EUR 147,00
☐ EUR 3.000.000
EUR 174,00
☐ EUR 4.000.000
EUR 199,50
☐ EUR 5.000.000
EUR 225,00
☐ EUR 6.000.000
EUR 375,00
ANCORA Vers.-Verm. GmbH
Grimm 14
20457 Hamburg
Telefon (040) 30 70 88-30
Telefax (040) 30 70 88-40
E-Mail: [email protected]
Geschäftsführer: Andreas Kaerger
Hamburg HRB 54398
Sitz der Gesellschaft: Hamburg
Register-Nr. D-C8WA-0K JVX-08
www.vermittlerregister.info
USt-Id Nr. DE223285529
Euro-Hanse GmbH
Große Elbstraße 212
22767 Hamburg
Telefon: (040) 380 37 260
Telefax: (040) 380 37 2619
Die ANCORA und die EURO-HANSE sind Versicherungsmakler mit einer Erlaubnis nach § 34d Abs. 1 der GewO
Versicherungsbeiträge sind umsatzsteuerfrei i. S. des UStG und der 6. EG-Richtlinie
Geschäftsführer: Mirko Samsinger
Hamburg HRB 51263
Register-Nr. D-01Y3-WDIHX-30
3a. Drone Information
Insurable from a single value (incl. Camera / Accessories) of € 4.000 (3a + 3b)
Drone-Typ Year of
Serial No. MTOM list price
used
flight data recorder
construction (required)
(kg)
onboard?
__________________________________________________________________________________________
☐yes ☐no ☐yes ☐no
__________________________________________________________________________________________
☐yes ☐no
☐yes ☐no
__________________________________________________________________________________________
☐yes ☐no ☐yes ☐no
3b Camera / accessories -Information (not fixed to the drone)
Make / Model Year of
Serial-No.
list price
used
other
construction (required)
__________________________________________________________________________________________
☐yes ☐no
__________________________________________________________________________________________
☐yes ☐no
__________________________________________________________________________________________
☐yes ☐no
Add supplement if necessary
4. Kasko-/ Electronics
Valid Area for Kasko / Electronics:
☐ Germany
☐ Germany + neighboring States
☐ Worldwide Cover
☐Europe (geographically)
add 3a) Total sum insured: EUR ____________________________
add 3b) Electronic-Insurance (only necessary if the camera for example not connected to the drone)
Sum insured: EUR ________________________________________
All the above premiums are in EUR plus VAT 19%.
Kasko- and Electronic premium incl. a no claim bonus of 30%
Grimm 14
20457 Hamburg
Telefon (040) 30 70 88-30
Telefax (040) 30 70 88-40
Hamburg HRB 54398
Euro-Hanse GmbH
22767 Hamburg
Telefon: (040) 380 37 260
Telefax: (040) 380 37 2619
Hamburg HRB 51263
5. Operation Information
I / we use the drone for the following:
☐ commercial
☐ scientific ☐ Police / official government ☐ Photo / Film
☐ surveillance flights
☐ agriculture ☐ other
Description:
__________________________________________________________________________________________
__________________________________________________________________________________________
Other risk-related Information like claims in the last 5 years:
__________________________________________________________________________________________
__________________________________________________________________________________________
I have taken note, that the information given by me in a discovery order issued by me, may be the subject of the
contract. Incorrect information can lead to refusal in the event of damage to cover. The Policyholder confirms
with the signature that all pilots of the drones received a briefing from the manufacture / trader.
Date / Town
signature of Policyholder / Applicant / seal
______________________
____________________________________________________________
Date / Town
signature of Insurance broker / seal
______________________
____________________________________________________________
Grimm 14
20457 Hamburg
Telefon (040) 30 70 88-30
Telefax (040) 30 70 88-40
Hamburg HRB 54398
Euro-Hanse GmbH
22767 Hamburg
Telefon: (040) 380 37 260
Telefax: (040) 380 37 2619
Hamburg HRB 51263

Risk questionnaire for drones

Transcrição

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