Drones RPAS PROPOSAL FORM. ITOO is an Authorised Financial Services Provider. FSP No

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1 POPOSAL FOM Drones PAS Underwritten by The Hollard Insurance Co. Ltd, an authorised Financial Services Provider ITOO is an Authorised Financial Services Provider. FSP No

2 1 GLOSSAY Please answer ALL questions completely Should any question or part thereof not be applicable, please state N/A Should insufficient space be provided, please continue on your company letterhead ATC CAA GCS MTOM OEM PAS OC FW/M Air Traffic Control Civil Aviation Authority Ground Control Station. Including launch system, flight control and mission specific hardware and software, communications equipment Maximum Take-off Mass Original Equipment Manufacturer emotely Piloted Air System. Complete operating system including airframe, payload, launch station and Ground Control Station PAS Operator Certificate Fixed Wing/Multi otor COVE TYPE EQUIED 1. Third Party Liability Yes No Compulsory - Covers liability to third parties for third party direct loss/damage consequential of PAS failure. Does not cover third parties consequential losses (e.g. Business Interruption) 2. Physical loss and damage to PAS Yes No Compulsory - Physical loss or damage to PAS (airframe, payload, launch station and/or GCS) in operating or routine testing environment 3. Spares Extension Yes No Physical loss or damage to PAS Spares (parts not attached to the PAS) 4. Hull War Extension Yes No Physical loss or damage to PAS as a consequence of a deliberate/malicious act or act of sabotage 5. War Liability Extension Yes No Third party Liability loss or damage as a consequence of a deliberate/malicious act or act of sabotage arising out of the use of the PAS 6. Cyber isk Extension Yes No Covers airborne Digital Assets, Non-Physical Business Interruption and Expenses, Computer Crime and Cyber Extortion (100,000 limit)

3 2 GENEAL Name of Insured Country in which registred Business Address Company Website Describe ALL business activities CETIFICATION OF PAS OPEATOS Certifying authority (state applicable CAA regulator) CAASA Other Name of PAS Operating Certificate (OC) holder Issue date of current OC PAS make, model and registration per PAS airframe: Note: questions below will follow same order for each airframe stated here FW or M FW or M FW or M INSUANCE POLICY LIMITS OF INDEMNITY Third party liability (Third Party/Premises/Hangarkeepers/Products) ZA () or USD ($) equired Limit equired Limit equired Limit

4 3 PAS physical loss/damage ZA () or USD ($) (Including airframe, launch station, GCS hardware and related software) PAS Spares ZA () or USD ($) (State value of payload and related spares specific to each airframe) Maximum Take Off Mass (MTOM) Including PAS airframe, navigation and comms and payload (KG) Maximum operating altitude (M) Maximum range (KM) Maximum endurance (HS) ) Has the Company or any of its PAS managers, operators or engineers previously been refused insurance coverage If YES, please specify Yes No Please provide a complete record of incidents and/or claims history

5 4 LAUNCH AND ECOVEY How does the PAS take-off (e.g. conventional undercarriage/launch rail/rocket assisted) Is the take-off/launch and/or recovery/landing fully autonomous, or is there an external pilot How does the PAS recover/land (ecovery net/parachute/conventional landing on undercarriage) NAVIGATION AND PAS COMMS Line of Sight GPS Navigation system and flight control software

6 5 edundancy (e.g. Pre-programmed holding pattern and/or line of sight operator control) Does the PAS have the ability to fly autonomously, or is manual input required at all times Flight control communications (type and range) single or dual comms link OPEATIONS Country (If present in more than one country please state additional countries) Current or intended usage of PAS by the Insured: Commercial (at third party premises for reward) Business Use (at own premises) Commercial (C) or Business Use (B) Commercial (C) or Business Use (B) Commercial (C) or Business Use (B) Intended operating environments (Please provide as much detail as possible and a % split)

7 6 Please also provide a % split between Commercial and Business usage Commercial (C) % or Business Use (B) % Commercial (C) % or Business Use (B) % Commercial (C) % or Business Use (B) % Will any hazardous flying take place (e.g. poor weather conditions or poor visibility, night flights, near to power line electro-magnetic fields, etc.) Please specify activity: Yes No Espected annual flying (Please separate by PAS airframe) hours Please confirm a log is kept for each Yes No hours flight / mission (in accordance with standard flight logs) Yes No hours Yes No Operator s Name/PL reference number/date of last issue A. Name PL ef. Date B Name PL ef. Date C Name PL ef. Date D Name PL ef. Date E Name PL ef. Date PESONAL ACCIDENT EXTENSION (For PL Operator Covers loss of Sight/Limb and Death) A. Name Cover Limit required Max 250,000) B. Name Cover Limit required Max 250,000) C. Name Cover Limit required Max 250,000) D. Name Cover Limit required Max 250,000) E. Name Cover Limit required Max 250,000)

8 7 DECLAATION I/We, the undersigned, declare that the statements set forth in this proposal form together with any other information supplied are true and correct and that I/we have not misstated or suppressed any material facts. I/We agree that this proposal form together with any other information supplied by me/us shall form the basis upon which the contract of insurance is concluded and shall be incorporated therein. I/We further undertake that in the event that the information provided changes between the date of this application and inception of cover, I/We will notify ITOO of such changes as soon as reasonably possible. Name (duly authorised) Designation Signature D D M M Y Y Y Y Date