Pilot History Form
Name
*
First Name
Last Name
Primary Named Insured on the policy is (or will be):
Myself
Someone Else
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
Employment History
Rows
Employer
Dates Employed
Occupation
1
2
Airman's Certificate No:
Limitations:
Medical Class:
Medical Issuance Date:
-
Month
-
Day
Year
Date
Certificate, Endorsements, and Ratings
*
Student
Private
Commercial
Airline Transport Pilot
Instructor
Instrument Rating
Helicopter
Sea Plane
Single Engine Land
Single Engine Sea
Multi-engine Land
Multi-engine Sea
Center Line Thrust
Glider
Airframe Technician
Powerplant
Inspection Authorization
Other
Total Logged Hours
Civilian and Military
Hours Logged by Category
*
Rows
Total Hours
Land
Piston Sea
Amphib
Turboprop
Jet
Single Engine - Fixed Wing
Multi-Engine - Fixed Wing
Rotor Wing
Experience by Make and Model
*
Rows
Make and Model Name
Total Hours
Last 90 days
Last 12 Months
SIC Total
SIC Last 90 days
SIC Last 12 Mo
1
2
3
4
5
Dual Instruction Given by Make and Model
*
Rows
Make and Model Name
Total Hours
Last 12 Months
1
2
3
Number of water landings last 12 months:
*
Tailwheel Hours:
*
Retract Hours:
*
Turbine AG Hours:
*
Specify make and model(s) on which approval is sought:
*
Seeking approval for:
*
PIC
SIC
Date of last biennial or annual flight review:
*
-
Month
-
Day
Year
Date
Where did you learn to fly?
*
(year, place and school of course completed)
List Manufacturer's Approved, Initial & Recurrent Ground & Flight Schools and Dates Attended
Rows
School Name
School Location
Make & Model
Dates
1
2
3
4
Incident History:
Have you ever had an aircraft claim, incident or accident?
*
Yes
No
Have you ever been investigated, cited or fined for violation of an aviation regulation?
*
Yes
No
Has your pilot certificate ever been suspended or revoked?
*
Yes
No
Have you ever been convicted of a felony or are you under indictment for a felony?
*
Yes
No
Have you ever been convicted of driving a motor vehicle under the influence of alcohol or narcotics, or of reckless driving?
*
Yes
No
Has your driver's license ever been suspended or revoked?
*
Yes
No
Have you ever been convicted of or are you under indictment in a legal action involving drugs or narcotics?
*
Yes
No
Explain each "Yes" answer fully:
I certify that the statements in this form are true to the best of my knowledge and belief, and I have not knowingly or intentionally concealed any pertinent information.
First Name
Last Name
Signature
Date Signed
-
Month
-
Day
Year
Date
Please verify that you are human
*
Submit
Should be Empty: