pilot-form-test Please enable JavaScript in your browser to complete this form. - Step 1 of 3Name *FirstLastAddress *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeLayoutEmail *Phone *Cell *LayoutAge *Driver's License State *AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingDriver's License Number *LayoutPresent Employer *Date Employed *Full Time/Part Time? *Select OneFull TimePart TimeJob Title *LayoutPercentage of Time Spent on Non-Flying Duties *Education: Highest Level Completed *Select OneHigh School or EquivalencySome CollegeAssociate's DegreeBachelor's DegreeMaster's DegreeDoctorateLayoutFAA Airman Certificate Number *Date of Last FAA Flight Physical *Class of Medical Certificate Held *Select OneFirstSecondThirdLayoutWaivers, Limitations or Conditions on Medical CertificatePhysical ImpairmentsLayoutDate of Last FAA Pilot Proficiency Check (BFR): *Type of Aircraft Used for Proficiency Check *Date of Last Instrument Proficiency Check (BFR *LayoutPilot Certificate/Ratings *StudentPrivateCommercialCFI-ACFI-ICFI-MEATP-SELATP-MELAircraft Ratings *Single Engine LandMulti Engine LandInstrumentSingle Engine SeaHelicopterOtherPlease List Other Ratings HereLayoutAircraft (Type Ratings)Mechanic RatingsAirframe & Powerplant (A+P)Inspection Authorization (IA)Total Logged Pilot Hours LayoutTotal Hours *Pilot in Command *Multi-EngineTurbo PropTurbo JetHours Last 12 Months in All Aircraft *NextBreakdown of Logged Pilot in Command Hours LayoutSINGLE ENGINE FIXED GEAR:SINGLE ENGINE RETRACTABLE GEAR:MULTI-ENGINE UNDER 12,500 LBS:MULTI-ENGINE OVER 12,500 LBS:SINGLE PILOT HOURS LOGGED IN AIRCRAFT REQUIRING A TYPE RATING:FIXED WING TURBO PROP:FIXED WING TURBO JET:INSTRUMENT FLYING:AERIAL APPLICATION:CONVENTIAL GEAR (TAILWHEEL): HELICOPTER - RECIPROCATING POWERED:HELICOPTER - TURBINE POWERED:INSTRUMENT FLYING, LAST 12 MONTHS:MILITARY HOURS LOGGED:ARE PILOT HOURS DOCUMENTED IN PILOT LOG BOOK? *YESNOAircraft You Are Requesting Insurance Approval to Operate LayoutAIRCRAFT 1, MAKE & MODEL: *AIRCRAFT 2, MAKE & MODEL:AIRCRAFT 3, MAKE & MODEL:AIRCRAFT 4, MAKE & MODEL:TOTAL HOURS FOR AIRCRAFT 1: *TOTAL HOURS FOR AIRCRAFT 2:TOTAL HOURS FOR AIRCRAFT 3:TOTAL HOURS FOR AIRCRAFT 4:HOURS LAST 12 MONTHS FOR AIRCRAFT 1: *HOURS LAST 12 MONTHS FOR AIRCRAFT 2:HOURS LAST 12 MONTHS FOR AIRCRAFT 3:HOURS LAST 12 MONTHS FOR AIRCRAFT 4:Training Courses Completed in the Last 2 Years LayoutMake & ModelSchoolCourseDate CompletedLayout (copy)Make & ModelSchoolCourseDate CompletedLayout (copy) (copy)Make & ModelSchoolCourseDate CompletedLayout (copy) (copy) (copy)Make & ModelSchoolCourseDate CompletedNextLoss History As pilot-in-command or co-pilot have you ever had an aircraft claim, incident or accident, or been cited or fined for violation of any aviation regulation of any country? *YESNOHas any FAA, Transport Canada, or military pilot certificate ever been suspended or revoked? *YESNOHave you ever been convicted of a felony or are you under indictment for a felony? *YESNOHave you ever been arrested, convicted of or pleaded guilty to a charge of reckless driving or driving a motor vehicleunder the influence of alcohol or narcotics? *YESNOHas your driver’s license ever been suspended or revoked? *YESNOHave you ever been convicted of or are you under indictment in a legal action involving drugs or narcotics? *YESNOHas any insurance company or underwriter cancelled, declined, or refused to renew any insurance on your behalf? *YESNOOther Comments (describing any of the answers above, as needed):FRAUD WARNING: 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 SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES. Signature *Clear SignatureSubmit
