Risk questionnaire for drones
Transcrição
Risk questionnaire for drones
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 E-Mail: [email protected] 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 Sitz der Gesellschaft: Hamburg Register-Nr. D-01Y3-WDIHX-30 www.vermittlerregister.info USt-Id Nr. DE118549596 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% 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 E-Mail: [email protected] 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 Sitz der Gesellschaft: Hamburg Register-Nr. D-01Y3-WDIHX-30 www.vermittlerregister.info USt-Id Nr. DE118549596 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 ______________________ ____________________________________________________________ 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 E-Mail: [email protected] 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 Sitz der Gesellschaft: Hamburg Register-Nr. D-01Y3-WDIHX-30 www.vermittlerregister.info USt-Id Nr. DE118549596