AIRCRAFT

What Aircraft will you be flying?

Aircraft Tail #

PILOT INFORMATION

Name

E-mail

Phone

Age

FLYING EXPERIENCE

Certificate

Multi Engine

IFR

Medical Class

Medical Date

Total Hours

Hours Last 12m

Tail Wheel

Retract Gear

Multi Engine

Turbine

MAKE & MODEL TIME

ie format...C152=50Hrs

Make Model 1

Make Model 2

Make Model 3

Make Model 4

TRAINING

BFR

IPC

IPC Details

Recurrent

PILOT RECORD

Have you had any Aviation Losses, Accidents, Claims, FAA Violations, FAA Waivers, DUI, Felony or Fraud convictions?

If Yes, Explain

FRAUD WARNING

Any person who knowingly and with intent to defraud, submits an application for insurance containing any materially false information or conceals information for the purpose of misleading the insurance company, commits a fraudulent insurance act which is a crime subject to criminal and civil penalties. By submitting this form I certify the information is accurate and true.