HomeMy WebLinkAbout20240257.tiffRESOLUTION
RE: APPROVE TWO (2) APPLICATIONS FOR HULL AND LIABILITY INSURANCE FOR
UNMANNED AIRCRAFT SYSTEMS (DRONES), AND AUTHORIZE CHAIR TO SIGN -
GLOBAL AEROSPACE, INC.
WHEREAS, the Board of County Commissioners of Weld County, Colorado, pursuant to
Colorado statute and the Weld County Home Rule Charter, is vested with the authority of
administering the affairs of Weld County, Colorado, and
WHEREAS, the Board has been presented with two (2) Applications for Hull and Liability
Insurance for Unmanned Aircraft Systems (Drones) from the County of Weld, State of Colorado,
by and through the Board of County Commissioners of Weld County, on behalf of the Departments
of Human Resources, Public Works, and the Sheriff's Office, to Global Aerospace, Inc.,
commencing upon full execution of signatures, with further terms and conditions being as stated
in said applications, and
WHEREAS, after review, the Board deems it advisable to approve said applications,
copies of which are attached hereto and incorporated herein by reference.
NOW, THEREFORE, BE IT RESOLVED by the Board of County Commissioners of
Weld County, Colorado, that the two (2) Applications for Hull and Liability Insurance for
Unmanned Aircraft Systems (Drones) from the County of Weld, State of Colorado, by and through
the Board of County Commissioners of Weld County, on behalf of the Departments of Human
Resources, Public Works, and the Sheriff's Office, to Global Aerospace, Inc., be, and hereby are,
approved.
BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized
to sign said applications.
cc'. pE (ZsMR/RR)
02/22 12H
2024-0257
EG0082
SO0045
PE0036
Date of signature:
TWO (2) APPLICATIONS FOR HULL AND LIABILITY INSURANCE FOR UNMANNED
AIRCRAFT SYSTEMS (DRONES) - GLOBAL AEROSPACE, INC.
PAGE 2
The above and foregoing Resolution was, on motion duly made and seconded, adopted
by the following vote on the 31st day of January, A.D., 2024.
BOARD OF COUNTY COMMISSIONERS
WELD COUNTY, C
ATTEST: ddeof44)
Weld County Clerk to the Board
B rn .1,0eut usIE L
Deputy Clerk to the Board
RM:
Attorney
Z(O(Z4
Kevin! Ross, Chair
rry L. Buc)q Pro-Tem
Mike Fr r eman
Scott"K. James
inc
2024-0257
EG0082
SO0045
PE0036
Con�vac+ 11) -nq 1,
BOARD OF COUNTY COMMISSIONERS
PASS -AROUND REVIEW
PASS AROUND TITLE: Drone Insurance Coverage Renewal Application
DEPARTMENT: Human Resources
PERSON REQUESTING: Michelle Raimer
DATE: 1/25/2024
Brief description of the problem/issue:
HR's Risk Team is applying to renew Unmanned Aircraft Systems (UAS) or Drone insurance. The Sheriffs Office currently operates two drones and
Public Works Pest & Weed Division operates five. The Sheriffs Office has four FAA certified pilots and Public Works has pilots and two more
employees in training. We want to renew this insurance coverage in the event of an accident.
What options exist for the Board?
Approval the UAS insurance coverage renewal
Denial of insurance renewal and seek other options for accident claims arbitration
Consequences:
Approve
Denial of insurance coverage and seek other options for claims arbitration
Impacts:
Instance renewal will ensure adequate loss recovery
Cost (Current Fiscal Year/Ongoing or Subsequent Fiscal Years:
Coverage cost for 3/27/23-3/27/24 current schedule was $9500
Recommendation:
it is recommended the Board of County Commissioners sign the renewal for UAS drone insurance coverage renewal.
Perry L Buck, Pro -Tern
Mike Freeman
Scott K. James
Kevin D. Ross, Chair
Lori Seine
(/31
Support Recommendation Schedule
Place on BOCC Agenda Work Session Other/Comments:
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B
2024-0257
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GLOBAL AEROSPACE
Other
APPLICATION FOR HULL AND LIABILITY INSURANCE
UNMANNED AIRCRAFT SYSTEMS
APPLICANT IS: O INDIVIDUAL(S) O CORPORATION O LLC O PARTNERSHIP O PUBLIC ENTITY ® OTHER cocaleountyGovernment
NAME OF APPLICANT (Including all affiliated names or Companies): Weld County
CONTACT NAME (in case we have any questions): Michelle Raimer, Kelly Leffler, Bonnie Adams
ADDRESS: 1150 O Street Greeley CO 80631
EMAIL ADDRESS: mraimer@weldgov.com l PHONE NUMBER: (970) 400-4233) APPLICANT WEBSITE: www.weld.gov
INSURANCE IS REQUESTED FROM 12:01 A.M. APPENDED TO 12:01 A.M. 03/27/2024 (local time at address of applicant)
❑ NEW INSURANCE POLICY RENEWAL POLICY Name of last aviation insurance carrier (if none, so state): Global Aerospace
BUSINESS OR OCCUPATION OF APPLICANT: Local County Government
❑ Individual Pricing
Choose this option if you have only a single drone or want physical
damage coverage for most of your drones. Each drone will have to be
entered as part of the quoting process.
O Group/Blanket Pricing (Only for drone units < 551bs)
Choose this option if you want liability coverage only or physical damage
coverage for just some of your drones. Only drones and equipment
requiring physical damage coverage will have to be entered as pad of the
quoting process. At the time of binding, you may be required to upload a
schedule of your current fleet of drones.
How many drones do you operate now? 2
How many drones do you plan to operate in a year's time? 4
Will all flights be conducted in accordance with applicable regulations, including no overflight of people unless in accordance with
the FAA rule for The Operation of Unmanned Aircraft Systems Over People, or with an appropriate waiver?
0 yes ❑ N.
Notwithstanding applicable regulations, will any flights be conducted (indoors or outdoors) at concerts or other events where
large numbers of people are present?
a yes O No
Do you intend to publish by any means data or images that were obtained or created by the operation of any UAS operated by
you or on your behalf?
0 Yes ❑ N.
Do you have procedures to control the publication of data or images?
Ni Yes ❑ No
Please select all intended uses of the UAS: (only select one main intended use if you require blanket liability, otherwise indicate all intended uses)
❑ Agriculture
0 Commercial Photography / Videography
0 Construction
0 Education, Research & Development
0 Events (Concerts / Sports / Weddings etc)
0 Fire Fighting / Support
❑ Infrastructure Inspection & Support
0 Instruction and Training
0 Law Enforcement
0 Mapping / Geophysical
0 Media / News Gathering
0 Military
❑ Movie /7V Production
0 Package Delivery
0 Private / Hobby
0 Property Survey / Inspection / Real Estate
❑ Sales / Demo
0 Search and Rescue
0 Surveillance
0 Wildlife / Conservation / Environmental
GLOBAL AEROSPACE, INC. Page 1 of 4
115 Tabor Road, Suite 3A, Morris Plains, NJ 07950 (973) 490-8500 FAX (973) 490-5600
G-31UASL (July2023)
GLOBAL AEROSPACE
Schedule
Equipment Ehat you owner that you rent/lease for more than 30 d
UAS Make and Mdel
Excluding payload/grounc equipment
Manufacture
Year
Registration / Serial
Number
UAS Insured
Value
Estimated annual
flight hours
Physical Damage
Coverage required?
DJI INNOVATIONS PHANTOM 4 PRO
2017
OAXDEIGQA3099
$ 5,500.00
50
® Yes ❑ No
DJI Matrice 300 RTI.:
2022
1ZNBJAJ00C0033
$ 26,000.00
100
15 Yes 0 No
$
® Yes ❑ No
Physical damage coverage also includes physical damage arising from, occasioned by or in consequence of war, hi -jacking and other perils such as
maliclous damage, saboege or any unlawful seizure or wrongful exercise of contra) of the aircraft.
Equipment that you own or that you rent/lease for more than 30 days for which physical damage coverage is required
UAS Ground Equipmentltutake
and Model and/or System and
Software
Serial Number
Insured
Value
DJI RC Plus
4LFCL5F005FX00
$1,600.00
$
UAS Payload
Make and Model
Serial Number
Insured
Value
DJI Zenmuse H2OT
11A/9DJ7H00103VVY
$14,000.00
CZI Gimbal spotlight GL60 Plus
6PSP211164
$2,199.0C
Spare Engines and Spare Parts which are owned by you or for which you are legally responsible
Is Physical Damage Coverage to Spare Engines and Spare Parts Required? I ❑ Yes X No Total Maximum Insured Value $
Non -Owned Physical Damage Coverage
Do you require insurance for any UAS that you do not own but which you will
operate for periods of tee than 30 days?
❑ Yes x No
Total Maximum Insured Value $
Do you require any insurance for any items of payload that you do not own but
which you will be using fir periods of less than 30 days?
❑ Yes No
Total Maximum Insured Value $
UAS Operators
Will all operations be conducted:
(a) By operators holding a valid Remote Pilot Airman Certificate with Small UAS Rating, or
(b) Under special exemption 49 U.S.C. 44807 in accordance with 14 CFR Part 11, or
(c) Under a Certificate of Authorization or Waiver (public entities only)?
Select 'Yes' if you will been compliance with one of the above before policy inception.
® Yes ❑ No
List minimum operator experience required by the applicant to operate UAS weighing 15lbs to less than 551bs:
Pilot Certification
Part 107 Certificate
Minimum Total
UAS Flight Hours
2 Hours
Minimum Total UAS
Model Flight Hours
1.5 Hours
List all orterators ofthe applicant's UAS, both employed and contract for UAS weighing 551bs and above:
Name
Date of Birth
Pilot Certification
Remote Pilot
Airman Certificate
Total UAS Flight
Hours
Total UAS Model
Flight Hours
a Yes 0 N
❑ Yes ❑ No
0 Yes 0 No
If you operate multiple UAS and use multiple operators, please attach the minimum experience and training applicable to each type of UAS flown.
Insurance & Claims Histo
In the last 3 years, have any of the operators (a) been cited for violation of any FAA regulations, or (b) had their pilot's or
driver's license suspended or (c) been convicted of driving while intoxicated or (d) of any felony charge?
❑ Yes X No
In the last 3 years, have wou been involved in any aircraft or UAS accidents or incidents?
❑ Yes X No
Please provide the details if you answered "Yes" to any of the above questions.
Liability Coveraje
LIMITS OF INSURANCE
EACH OCCURRENCE LIMIT
Single Limit Bodily Injury and Property Damage Liability:
Also includes Liability arie+ng from:
occasioned by Dr in consequence of war hi -jacking and other perils
the operation a' UAS you rent/lease/borrow for periods of less than 30 days
UAS operated 3n your behalf by others
Personal Injury Liability:
$ $1,000,000.00
$ $1,000.000,00
GLOBAL AEROSPACE, INC.
115 Tabor Road, Suite 3A, Morris Plains, NJ 07950 (973) 490-8500 FAX (973) 490-5600
G-31UASL (July 2023)
Page 2 of 4
GLOBAL AEROSPACE
Acts of Terrorism under the TRIPRA
Coverage for Acts of Terrorism under the Terrorism Risk Insurance Program Reauthorization Act of
2007 and 2015 (TRIPRA). Coverage prodded for bodily injury and property damage for which you
may be liable for certified acts of terrorism.
This coverage is automatically quoted if the
below box is left unchecked
I wish to decline TRIPRA coverage. 0
Has any insurance company or underwriter at any time declined an application submitted by or canceled or refused to renew a policy held by the
applicant or any of the pilots named herein with regard to any type of insurance? NOT APPLICABLE IN MO ❑ Yes 0 No If so, explain
circumstances:
FRAUD STATEMENTS
Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing
any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a
fraudulent insurance act, which is a crime and subjects that person to criminal and civil penalties Its Oregon, the aforementioned actions may
constitute a fraudulent insurance act which may be a crime and may subject the person to penalties). (In New York, the civil penalty is not to
exceed five thousand dollars ($5,000) and the stated value of the claim for each such violation). (Not applicable in AL, AR, AZ, CO, DC, FL, KS,
LA, ME, MD, MN, NM, OK, PR, RI, TN, VA, VT, WA and WV).
APPLICABLE IN AL, AR, AZ, DC, LA, MD, NM, RI and WV
Any person who knowingly (or willfully in MD) presents a false or fraudulent claim for payment of a loss or benefit or who knowingly (or willfully in MD)
presents false information in an application for insurance is guilty of a crime and may be subject to fines or confinement in prison.
APPLICABLE IN COLORADO
It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or
attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or
agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the
purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall
be reported to the Colorado Division of Insurance within the department of regulatory agencies.
APPLICABLE IN FLORIDA and OKLAHOMA
Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false,
incomplete, or misleading information is guilty of a felony (In FL, a person is guilty of a felony of the third degree).
APPLICABLE IN KANSAS
Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to
or by an insurer, purported insurer, broker or any agent thereof, any written statement as part of, or in support of, an application for the issuance of, or
the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for
commercial or personal insurance which such person knows to contain materially false information concerning any fact material thereto; or conceals, for
the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act.
APPLICABLE IN MAINE, TENNESSEE, VIRGINIA and WASHINGTON
It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company.
Penalties may include imprisonment, fines or a denial of insurance benefits.
APPUCABLE IN MINNESOTA
A person who files a claim with intent to defraud, or helps commit a fraud against an insurer, is guilty of a crime.
APPLICABLE IN PUERTO RICO
Any person who knowingly and with the intention of defrauding presents false information in an insurance application, or presents, helps, or causes the
presentation of a fraudulent claim for the payment of a loss or any other benefit, or presents mom than one claim for the same damage or loss, shall
incur a felony and, upon conviction, shall be sanctioned for each violation by a fine of not less than five thousand dollars ($5,000) and not more than ten
thousand dollars (510,0001, or a fixed term of imprisonment for three (3) years, or both penalties. Should aggravating circumstances be present, the
penalty thus established may be increased to a maximum of five(5) years, if extenuating circumstances are present, it may be reduced to a minimum of
two (2) years.
APPUCABLE IN VERMONT
Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and may be subject to penalties
under state law.
All particulars herein am declared to be true and complete to the best of mylour knowledge and no information has been withheld or
suppressed and Ilwe agree that this application and the tens and conditions of the policy in use by the insurer shall be the basis of any
contract between me/us and the insurer. I hereby authorize��he ips� ur to ualiflc tion o s tem is contained
herein. Kevin , ss, air and of Weld County
JAN 3 I. 2024 ' _Y' Commissioners
Date Applicant's
GLOBAL AEROSPACE, INC.
115 Tabor Road, Suite 3A, Morris Plains, NJ 07950 (973) 490-8500 FAX (973) 490-5600
G-31 UASL (July 2023)
Page 3 of 4
oto.2 c.257(-,
GLOBAL AEROSPACE
THIS APPLICATION DUPES NOT COMMIT THE INSURER TO ANY LIABILITY NOR MAKE THE APPLICANT LIABLE FOR ANY PREMIUM
UNLESS AND UNTIL TIE INSURER AGREES TO EFFECT THIS INSURANCE.
THE INSURANCE PRODUCER COMPLETES THE BELOW SECTION.
Name of Insurance ProdtJcer:
State License Number:
I License State:
Address:
For how long have you been designated this applicanEs Broker of Record?
GLOBAL AEROSPACE, INC. Page 4 of 4
115 Tabor Road, Suite 3A, Morris Plains, NJ 07950 (973) 490-8500 FAX (973) 490-5600
G-31UASL (July 2023)
APPENDIX
What is the desired effective date of the policy currently being applied for? 03/27/2024
WCSO Drone Operators
Name
1 Deputy Christopher Dalzel
2 Deputy Spencer Rougier
3 Deputy Matthew Tippetts
4 Deputy Sean Harvey
UAS Certificate of Registration
UAS Make & Model
DJI Phantom 4
DJI Matrice 300
FAA Pilot Certification Number
4661956
4739995
4654452
4782933
Serial Number
07JDDC000100UK
1ZN BJAJ00C0033
FA3MRM49XC
FA3 M RLYETL
FAA Registration # Issue Date Expiration Date
10/12/2022 10/12/2025
10/12/2022 10/12/2025
GLOBALAER0SPACE
Other
APPLICATION FOR HULL AND LIABILITY INSURANCE
UNMANNED AIRCRAFT SYSTEMS
APPLICANT IS: 0 INDIVIDUAL(S) 0 CORPORATION 0 LLC 0 PARTNERSHIP 0 PUBLIC ENTITY 0 OTHER Local caun0Government
NAME OF APPLICANT (including Al affiliated names or Companies): Weld County
CONTACT NAME (in case we have any questions): Michelle Raimer, Kelly Leffler, Bonnie Adams
ADDRESS: 1150 O Street Greeley CO 80631
EMAIL ADDRESS:mraimer@weldgov.com I PHONE NUMBER: (970) 400-4233[ APPLICANTWEBSITE: www.weld.gov
INSURANCE IS REQUESTED FROM 12:01 A.M. opcoeoeo TO 12:01 A.M. 03/27/2024 (local time at address of applicant)
0 NEW INSURANCE POLICY (fr RENEWAL POLICY Name of last aviation insurance carrier (if none, so state): Global Aerospace
BUSINESS OR OCCUPATION OF APPLICANT: Local County Government
OaerationS
❑ Individual Pricing
Choose this option if you have only a single drone or want physical
damage coverage for most of your drones. Each drone will have to be
entered as part of the quoting process.
0 Group/Blanket Pricing (Only for drone units < 551bs)
Choose this option if you want liability coverage only or physical damage
coverage for just some of your drones. Only drones and equipment
requiring physical damage coverage will have to be entered as pall of the
quoting process. At the time of binding, you may be required to upload a
schedule of your current fleet of drones.
How many drones do you operate now? 5
How many drones do you plan to operate in a year's time? 7..
WI) all flights be conducted in accordance with applicable regulations, including no overflight of people unless in accordance with
the FAA rule for The Operation of Unmanned Aircraft Systems Over People, or with an appropriate waiver?
® Yes ❑ No
Notwithstanding applicable regulations, will any flights be conducted (indoors or outdoors) at concerts or other events where
large numbers of people are present?
❑ yes p No
Do you intend to publish by any means data or images that were obtained or created by the operation of any UAS operated by
you or on your behalf?
® yes ❑ No
Do you have procedures to control the publication of data or images?
N Yes ❑ No
Please select all intended uses of the OAS: (only select one main intended use if you require blanket liability, otherwise indicate all intended uses)
K1 Agriculture
O Commercial Photography / Videography
MI Construction
® Education, Research & Development
O Events (Concerts! Sports / Weddings etc)
O Fire Fighting / Support
e Infrastructure Inspection & Support
❑ Instruction and Training
O Law Enforcement
® Mapping / Geophysical
O Media / News Gathering
O Military
❑ Movie /TV Production
O Package Delivery
O Private / Hobby
p Property Survey / Inspection / Real Estate
❑ Sales / Demo
❑ Search and Rescue
❑ Surveillance
O Wildlife / Conservation / Environmental
GLOBAL AEROSPACE, INC. Page 1 of 4
115 Tabor Road, Suite 3A, Morris Plains, NJ 07950 (973) 490-8500 FAX (973) 490-5800
G-31UASL (July 2023)
GLOBAL AEROSPACE
Schedule
Equipment that you owe or that you renVlease for more than 30
UAS Make and Model
Excluding payload/groucl equipment
Manufacture
Year
Registration / Serial
Number
UAS Insured
Value
Estimated annual
flight hours
Physical Damage
Coverage required?
See attached supplement
s
❑ Yes ❑ No
$
❑Yes 0 N
$
❑Yes 0 N
Physical damage coverage also includes physical damage arising from, occasioned by or in consequence of war, hi -jacking and other perils such as
malicious damage, sabeage or any unlawful seizure or wrongful exercise of control of the aircraft.
Equipment that you owr or that you rent/lease for more than 30 days for which physical damage coverage is required
UAS Ground Equipmers Make
and Model and/or System and
Software
Serial Number
Insured
Value
$
UAS Payload
Make and Model
Serial Number
Insured
Value
$
Spare Engines and Spare Pads which are owned by you or for which you are legally responsible
Is Physical Damage Cacerage to Spare Engines and Spare Parts Required? I ❑ Yes X No I Total Maximum Insured Value $
Non -Owned Physical Damage Coverage
Do you require insuranai for any UAS that you do not own but which you will
operate for periods of leas than 30 days?
❑ Yes g No
Total Maximum Insured Value $
Do you require any insurance for any items of payload that you do not own but
which you will be using ar periods of less than 30 days?
❑ Yes X No
Total Maximum Insured Value $
UAS Operators
Will all operations be conducted:
(a) By operators bolding a valid Remote Pilot Airman Certificate with Small UAS Rating, or
(b) Under speciabexemption 49 U.S.C. 44807 in accordance with 14 CFR Pad 11, or
(c) Under a Certificate of Authorization or Waiver (public entities only)?
Select 'Yes' if you will be in compliance with one of the above before policy inception.
Yes ❑ No
List minimum operator experience required by the applicant to operate UAS weighing 151bs to less than 551bs:
Pilot Certification
Minimum Total
UAS Flight Hours
Minimum Total UAS
Model Fight Hours
Part 107 Certificate
2 Hours
1.5 Hours
List all operators o` the applicant's UAS. both employed and contract for UAS welshing 551bs and above:
Name
Date of Birth
Pilot Certification
Remote Pilot
Airman Certificate
Total UAS Flight
Hours
Total UAS Model
Flight Hours
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
If you operate multiple U/6 and use multiple operators, please attach the minimum experience and training apploabte to each type of UAS flown.
Insurance & Claims History
In the last 3 years, haveany of the operators (a) been cited for violation of any FAA regulations, or (b) had their pilot's or
driver's license suspentfed or (e) been convicted of driving while intoxicated or (d) of any felony charge?
❑ Yes Ot No
In the last 3 years, havegou been involved in any aircraft or UAS accidents or incidents?
❑ Yes IX No
Please provide the detail if you answered "Yes" to any of the above questions.
Liability_ Coverage
LIMITS OF INSURANCE
EACH OCCURRENCE LIMIT
Single Limit Bodily Injuryrand Property Damage Liability:
Also includes Liability arcing from:
occasioned bk or in consequence of war hi -jacking and other perils
the operation of UAS you rent/leaselborrow for periods of less than 30 days
UAS operatedbn your behalf by others
Personal Injury Liability:
$ $1,000,000.00
$ $1,000,000.00
GLOBAL AEROSPACE, INC.
115 Tabor Road, Suite 3A, Morris Plains, NJ 07950 (973) 490-6500 FAX (973) 490-5600
G-31 UASL (July 2023)
Page 2 of 4
GLOBALAEROSPACE
Acts of Terrorism under the TRIPRA
Coverage for Acts of Terrorism under the Terrorism Risk Insurance Program Reauthorization Act of
2007 and 2015 (TRIPRA). Coverage provided for bodily injury and property damage for which you
maybe liable for certified acts of terrorism.
This coverage is automatically quoted if the
below box Is left unchecked
I wish to decline TRIPRA coverage. O
Has any insurance company or underwriter at any time declined an application submitted by or canceled or refused to renew a policy held by the
applicant or any of the pilots named herein with regard to any type of insurance? NOT APPLICABLE IN MO ❑ Yes ❑ No If so, explain
circumstances:
FRAUD STATEMENTS
Any person who knowingly and with intent to defraud any insurance company or other person files an application for Insurance containing
any materially false Information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a
fraudulent insurance act, which is a crime and subjects that person to criminal and civil penalties (In Oregon, the aforementioned actions may
constitute a fraudulent insurance act which may be a crime and may subject the person to penalties). (In New York, the civil penalty is not to
exceed five thousand dollars ($5,000) and the stated value of the claim for each such violation). (Not applicable in AL, AR, AZ, CO, DC, FL, KS,
LA, ME, MD, MN, NM, OK, PR, RI, TN, VA, VT, WA and WV).
APPLICABLE IN AL, AR, AZ, DC, LA, MD, NM, RI and WV
Any person who knowingly (or willfully In MD) presents a false or fraudulent claim for payment of a loss or benefit or who knowingly (or willfully in MD)
presents false information in an application for Insurance is guilty of a crime and may be subject to fines or confinement in prison.
APPLICABLE IN COLORADO
It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or
attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or
agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the
purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall
be reported to the Colorado Division of Insurance within the department of regulatory agencies.
APPLICABLE IN FLORIDA and OKLAHOMA
Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false,
incomplete, or misleading information is guilty of a felony (In FL, a person is guilty of a felony of the third degree).
APPLICABLE IN KANSAS
Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to
or by an insurer, purported insurer, broker or any agent thereof, any written statement as part of, or in support of, an application for the issuance of, or
the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for
commercial or personal insurance which such person knows to contain materially false information concerning any fact material thereto; or conceals, for
the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act.
APPLICABLE IN MAINE, TENNESSEE, VIRGINIA and WASHINGTON
It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company.
Penalties may include imprisonment, fines or a denial of insurance benefits.
APPLICABLE IN MINNESOTA
A person who files a claim with intent to defraud, or helps commit a fraud against an insurer, is guilty of a crime.
APPLICABLE IN PUERTO RICO
Any person who knowingly and with the intention of defrauding presents false information in an Insurance application, or presents, helps, or causes the
presentation of a fraudulent claim for the payment of a loss or any other benefit, or presents more than one claim for the same damage or loss, shall
incur a felony and, upon conviction, shall be sanctioned for each violation by a fine of not less than five thousand dollars ($5,000) and not more than ten
thousand dollars ($10,000), or a fixed term of imprisonment for three (3) years, or both penalties. Should aggravating circumstances be present, the
penalty thus established may be increased to a maximum of five(5) years, if extenuating circumstances are present, it may be reduced to a minimum of
two (2) years.
APPLICABLE IN VERMONT
Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and may be subject to penalties
under state law.
All particulars herein are declared to be true and complete to the best of my/our knowledge and no information has been withheld or
suppressed and Uwe agree that this application and the terms and conditions of the policy in use by the insurer shall be the basis of any
contract between me/us and the insurer. I hereby authorize the insurer to investi ate all or an qualifications or statements contained
herein. Kevin D. Ross, Chair,
o e my Commissioners
Date JAN 312024 Applicant's Signature(s) ✓�— (3. rZ
GLOBAL AEROSPACE, INC.
115 Tabor Road, Suite 3A, Morns Plains, NJ 07950 (973) 490-8500 FAX (973) 490-5600
G-31UASL (July2023)
Page 3 of 4
02,0a4-ea57(0
CLOBALAEROSPACL
THIS APPLICATION ®ES NOT COMMIT THE INSURER TO ANY LIABILITY NOR MAKE THE APPLICANT LIABLE FOR ANY PREMIUM
UNLESS AND UNTIL THE INSURER AGREES TO EFFECT THIS INSURANCE.
THE INSURANCE PRODUCER COMPLETES THE BELOW SECTION.
Name of Insurance Producer:
State License Number:
I License State:
Address:
For how long have you teen designated this applicant's Broker of Record?
GLOBAL AEROSPACE, INC. Page 4 of 4
115 Tabor Road, Suite 3A, Morris Plains, NJ 07950 (973) 490-8500 FAX (973) 490-5800
G-31UASL (July 2023)
APPENDIX
What is the desired effective date of the policy currently being applied for? 03/27/2024
UAS Make & Model
Parrot Anafi
Parrot Anafi
DJI Mini 3 Pro
Manuf.
Year
2020
2020
2023
DJI Mavic 3 multispectral
Hylio Ag210
Public Works Pilots
2023
2023
Serial Number
PS728000BA8H085981
PS728000BA8H086103
1581 F4XFA22CEM L85 E96
1581F5FKD233200D7WJ7
17906080202
FAA Registration #
FA3E7AEMXC
FA3E7AARTL
FA33N43NNR
FA3AC9E7A3
FA3HHFKT7K
UAS Insured
Value
1000.00
1000.00
1200.00
5000.00
18,000.00
Estimated
Annual Flight
Hours
5 hours
5 hours
16 hours
13 hours
7 hours
Physical
Damage
Coverage
Yes
Yes
Yes
Name
Date of Birth
Pilot Certification
Remote Pilot Airman
Certificate
Total UAS Flight
Hours
21 hours
Total UAS Model
Flight Hours
1.5 hours
Tina Harvey
Greg Hoff
10/1972
4259617
YES
Travis Smith
08/1978
4802922
YES
5 hours
1.5 hours
Kevin Smith
06/1982
4635182
YES
2 hours
Phil Kinnison
08/1991
4696785
YES
2 hours
Nick Marquez
04/1987
/
4286883
YES
3 hours
KathyGriffee
08/1971
4894239
YES
9 hours
Mark
09/1968
4596105
YES
2 hours
1.5 hours
Derrera
Mike
11/1969
NO
2 hours
Smith
01/1990
NO
2 hours
Only staff with the yellow highlight will be flying the Hylio Spray drone which is above 15 pounds and below 55 pounds. These 3 staff members
will be on the part 137 waiver from FAA. All other staff are flying small quadcopters less than 5 pounds.
TWO (2) APPLICATIONS FOR HULL AND LIABILITY INSURANCE FOR UNMANNED
AIRCRAFT SYSTEMS (DRONES) - GLOBAL AEROSPACE, INC.
APPROVED AS TO SUBSTANCE:
e
APPROVED AS TO FUNDING:
Elected Official
Pak
Chief Financial Officer, or Controller
APPROVED AS TO FORM:
15XiLe‘27
County Attorney
Hello