Pilot History Form
DRIVER'S LICENSE STATE
DRIVER'S LICENSE NUMBER
FAA AIRMAN CERTIFICATE NUMBER
DATE OF LAST FAA FLIGHT PHYSICAL
CLASS OF MEDICAL CERTIFICATE HELD
WAIVERS, LIMITATIONS OR CONDITIONS ON MEDICAL CERTIFICATE
DATE OF LAST FAA BIENNIAL FLIGHT REVIEW (BFR)
TYPE OF AIRCRAFT USED FOR BFR
DATE OF LAST INSTRUMENT PROFICIENCY CHECK
AIRCRAFT (TYPE RATINGS)
TOTAL LOGGED PILOT HOURS
PILOT IN COMMAND:
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, LAST 12 MONTHS:
MULTI-ENGINE OVER 12,500 LBS:
MILITARY HOURS LOGGED:
SINGLE PILOT HOURS IN AIRCRAFT REQUIRING A TYPE RATING:
CONVENTIONAL GEAR (TAILWHEEL):
ARE PILOT HOURS DOCUMENTED IN PILOT LOG BOOK?:
AIRCRAFT 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:
AIRCRAFT 3, MAKE & MODEL:
AIRCRAFT 4, MAKE & MODEL:
TRAINING COURSES COMPLETED IN THE LAST 2 YEARS
MAKE & MODEL:
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):
Leave this empty:
Your legal name
Your email address
If you have questions about the contents of this document, you can email the document owner.
Document Name: Pilot History Form
Agree & Sign