Kassel Aviation Insurance

Pilot History Form


   

PILOT'S NAME

ADDRESS

EMAIL

PHONE

CELL

AGE

DRIVER'S LICENSE STATE

DRIVER'S LICENSE NUMBER

PRESENT EMPLOYER

DATE EMPLOYED

FULL/PART TIME

POSITION HELD

% OF TIME SPENT ON NON-FLYING DUTIES

EDUCATION: HIGHEST LEVEL COMPLETED

ARE YOU A PROFESSIONAL PILOT?

*Professional pilot is defined as any person(s) who has their main source of income derived from their responsibilities acting as a required flight crew member of an aircraft.

FAA AIRMAN CERTIFICATE NUMBER

DATE OF LAST FAA FLIGHT PHYSICAL

CLASS OF MEDICAL CERTIFICATE HELD

WAIVERS, LIMITATIONS OR CONDITIONS ON MEDICAL CERTIFICATE

PHYSICAL IMPAIRMENTS

DATE OF LAST FAA BIENNIAL FLIGHT REVIEW (BFR)

TYPE OF AIRCRAFT USED FOR BFR

DATE OF LAST INSTRUMENT PROFICIENCY CHECK


PILOT CERTIFICATE/RATINGS

AIRCRAFT RATINGS

AIRCRAFT (TYPE RATINGS)

MECHANIC RATINGS


TOTAL LOGGED PILOT HOURS

TOTAL HOURS:

PILOT IN COMMAND:

MULTI-ENGINE:

TURBO PROP:

TURBO JET:

HOURS LAST 12 MO. - ALL AIRCRAFT:


BREAKDOWN OF LOGGED PILOT IN COMMAND HOURS

SINGLE ENGINE FIXED GEAR:

FIXED WING TURBO PROP:

HELICOPTER - RECIPROCATING POWERED:

SINGLE ENGINE RETRACTABLE GEAR:

FIXED WING TURBO JET:

HELICOPTER - TURBINE POWERED:

MULTI-ENGINE UNDER 12,500 LBS:

INSTRUMENT FLYING:

INSTRUMENT FLYING, LAST 12 MONTHS:

MULTI-ENGINE OVER 12,500 LBS:

AERIAL APPLICATION:

MILITARY HOURS LOGGED:

SINGLE PILOT HOURS IN AIRCRAFT REQUIRING A TYPE RATING:

CONVENTIONAL GEAR (TAILWHEEL):

ARE PILOT HOURS DOCUMENTED IN PILOT LOG BOOK?:


AIRCRAFT MODEL YOU ARE REQUESTING INSURANCE APPROVAL TO OPERATE

AIRCRAFT 1, MAKE & MODEL:

TOTAL HOURS FOR THIS AIRCRAFT:

HOURS LAST 12 MONTHS FOR THIS AIRCRAFT:

AIRCRAFT 2, MAKE & MODEL:

TOTAL HOURS FOR THIS AIRCRAFT:

HOURS LAST 12 MONTHS FOR THIS AIRCRAFT:

AIRCRAFT 3, MAKE & MODEL:

TOTAL HOURS FOR THIS AIRCRAFT:

HOURS LAST 12 MONTHS FOR THIS AIRCRAFT:

AIRCRAFT 4, MAKE & MODEL:

TOTAL HOURS FOR THIS AIRCRAFT:

HOURS LAST 12 MONTHS FOR THIS AIRCRAFT:


TRAINING COURSES COMPLETED IN THE LAST 2 YEARS

MAKE & MODEL:

SCHOOL:
COURSE:

DATE COMPLETED:

MAKE & MODEL:

SCHOOL:
COURSE:

DATE COMPLETED:

MAKE & MODEL:

SCHOOL:
COURSE:

DATE COMPLETED:

MAKE & MODEL:

SCHOOL:
COURSE:

DATE COMPLETED:

 

LOSS 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?

Has any FAA, Transport Canada, or military pilot certificate ever been suspended or revoked?

Have you ever been convicted of a felony or are you under indictment for a felony?

Have you ever been arrested, convicted of or pleaded guilty to a charge of reckless driving or driving a motor vehicle under the influence of alcohol or narcotics?

Has your driver’s license ever been suspended or revoked?

Have you ever been convicted of or are you under indictment in a legal action involving drugs or narcotics?

Has any insurance company or underwriter cancelled, declined, or refused to renew any insurance on your behalf?

Other Comments (describing any of the answers above, as needed):

 

** THIS PILOT EXPERIENCE FORM IS FILED IN CONNECTION WITH POLICYHOLDER/AIRCRAFT OWNER:

Name:

Leave this empty:

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Signature Certificate
Document name: Pilot History Form
lock iconUnique Document ID: e35333e5e55f117be685e3a950811a42ea736bbe
Timestamp Audit
May 22, 2023 3:38 pm EDTPilot History Form Uploaded by Shannon Hope - info@kasselaviation.com IP 135.84.11.94
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