Pilot History

If you would like us to contact you please complete the form below. This information is for internal use only; none of the following will be distributed to any other parties. See our privacy statement for more information.

* Indicates a required field

*Name of Insured:
*PILOT'S NAME:
*Address:
*City:
*State:
*Zip:
*Please provide Email Address or Work Phone:
Email Address:
Work Phone:
Home Phone:
 
Date of Birth:
Marital Status:
# of Children:
Occupation:
Employer and Duration:
Airman's Certificate No.:
 
Auto Driver's Lic. No.:
State:
 

CERTIFICATES and RATINGS

Student
Private
Commercial
ATP
Instructor
Instrument Rating
Multi-Engine Land
Helicopter
Glider
Balloon
Other (Specify):
 
Type Ratings:
Medical Date:
Medical Class:
Last BFR Date:
 

TOTAL LOGGED PILOT HOURS

TOTAL TIME:
TOTAL PIC TIME:
Single Engine Fixed Gear:
Single Engine Retr. Gear:
Conventional Gear (Tail Dragger):
Twin Engine Under 12,500# Gross:
Turbo Prop:
Turbo Jet:
Twin Engine Over 12,500# Gross:
Helo. - Reciprocating Engine:
Helo. - Turbine Powered:
Last 90 Days:
Last 12 Months:
Agricultural Total:
Agricultural Turbine:
Agricultural Rotor:
 

APPLICANT REQUESTS APPROVAL in the FOLLOWING MAKE & MODEL of AIRCRAFT

Make/Model of Aircraft to be insured:
Total Logged Pilot Hours in the Aircraft:
 
Is Annual Recurrent Training received in this Aircraft?
Where?/When?
 
 
1) Do you hold a current FSI Pro Card or Simuflite Card?
2) Do you Participate in FAA Pilot Proficiency Award Program?
  If yes, check the highest Phase completed:
I II III IV V VI VII VIII IX X
or enter other Phase:
  For what type of aircraft:
3) Refresher/Transition Courses?
  Please list and describe and give dates of last course attended:
4) Are you flying under a waiver?
5) Have you ever been penalized for an FAR violation?
6) Have you ever had an Aircraft Accident/Incident or Violation?
7) Has any insurance company or underwriter cancelled, declined or refused to renew any insurance on your behalf?
8) Have you ever been convicted of driving a motor vehicle under the influence of alcohol or narcotics, or of reckless driving?
9) Has your driver's license ever been suspended or revoked?
10) Have you ever been convicted of or are you under indictment in a legal action involving drugs or narcotics?
 
If you answered yes to question 4 through 10 please provide an in-depth explanation. Your candid and complete description of the situation will assist us in our negotiations with the insurance underwriters.
 

By clicking submit you warrant the truth of the above statements and further WARRANT that no material information has been withheld or suppressed.

 

[ back to top ]