Aviation Insurance :: Aircraft Insurance, Helicopter Insurance and Pilot Life Insurance

Insured Information

New purchase?

Yes No

First Name

Last Name

DOB

Employer / Occupation


Medical Certificate Information
Medical Date (ex: mm/yyyy)
Class Class I Class II Class III
Limitations

Airman Certificates and Ratings
Certificate Number
Student Light Sport Private Commercial Airline (ATP)	Instrument Single Engine - Land Single Engine - Sea Multi-Engine - Land Multi-Engine - Sea	Additional TYPE ratings?:
		Rotorcraft


Flight and Ground School Training Courses

Name and Location of School		Date Completed (mm/yyyy)
In Aircraft In Simulator	Model & Type of Aircraft


Logged Pilot Hours		= Total Pilot-In-Command for all aircraft
	TOTAL HOURS	LAST 12 MONTHS
Single-Engine (Fixed Gear):	Total Hours	Last 12 Months:	Total Hours
Single-Engine (Retractable):	Total Hours	Last 12 Months:	Total Hours
Multi-Engine (Piston):	Total Hours	Last 12 Months:	Total Hours
Turbo-Prop:	Total Hours	Last 12 Months:	Total Hours
Jet:	Total Hours	Last 12 Months:	Total Hours

1. Have you ever had an aircraft claim, incident or accident?

Yes No

2. Have you ever been cited or fined for violation of an aviation regulation?

Yes No

3. Has your pilot certificate ever been suspended or revoked?

Yes No

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

Yes No

5. Have you ever been convicted of driving a motor vehicle under the influence of alcohol or narcotics, or of reckless driving?

Yes No

6. Has your drivers license ever been suspended or revoked?

Yes No

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

Yes No

8. Have you ever had or been treated for a chemical dependency?

Yes No

9. Are you regularly using any medication?

Yes No