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PILOT HISTORY FORM
1. GENERAL INFORMATION
 
Pilot's Name
Address
City
State
Zip
Phone
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Email
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Date Of Birth
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Employer
Name Insured
   
   
2. PILOT EXPERIENCE  
   
Total Time All Aircraft
Total Time Fixed Wing
Total Time Rotor Wing
Total Time Turbine Rotor Wing
Total Time Multi-Engine
Total Turbine (SIC+PIC)
Total Turbine (PIC)
Total Time Turbo Jet (SIC+PIC)
Total Time Turbo Jet (PIC)
Total Instrument Time
Total Time Conventional Gear
Total Time Last 12 months
Date Last BFR
Date Last Medical
   
   
3. INSURED MAKE AND MODEL  
   
Insured Make & Model #1
Total Time MM
Date/Place Last Formal Training
 
Insured Make & Model #2
Total Time MM
Date/Place Last Formal Training
   
   
4. TYPE RATINGS  
   
List All
   
Check All That Apply
Private Pilot
Commercial Pilot
 
ATP
Flight Instructor
 
Designated Examiner
Instrument
 
Multi-Engine Land
Helicopter
 
Pro-Pilot Full Time
Pro Card
 
1st Class Medical
2nd Class Medical
 
3rd Class Medical
No Accidents
 
No Waivers
No Violations
   
   
5. QUESTIONS Check "Yes" or "No"
   
Are you flying under a waiver?
Yes
No
 
Have you ever been penalized for an FAR violation?
Yes
No
 
Have you ever had an aircraft incident, accident, and/or violation?
Yes
No
 
Has any insurance company/underwriter ever cancelled, non-renewed, or declined coverage on your behalf?
Yes
No
 
Have you ever been convicted of, or are you under indictment in a legal action involving drugs or narcotics?
Yes
No
   
Have you ever been convicted of driving a motor vehicle under the influence of alcohol or narcotics?
Yes
No
   
Has your driver's license ever been suspended or revoked?
Yes
No
 
Please explain all yes answers
   
Pilot's Signature
(Electronic signature is required)
  I understand that my signature on this written declaration has the same legal effect as an oath or affirmation. Under penalties of perjury, I declare that I have read the foregoing application and the facts stated in it are true. I understand that falsification of any material information on this application may result in criminal penalty or administrative action, including a fine, suspension or revocation of the license. I understand that an electronic signature shall have the same force and effect as a written signature.
Date
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