Pilot History Form

Requester Information

Make and Model of Aircraft to be Flown *

This pilot record is filed in connection with the insurance application of: *Tail NumberPolicy Holder Name/CompanyPolicy NumberPlease select one of these options so we can identify to which policy we will be adding this pilot.

Tail Number *

Policy Holder Name/Company *

Policy Number *

Pilot Details

First Name *

Last Name *

Email *

Phone *

Street Address *

Apartment, suite, etc

City *

State *

ZIP *

Birthdate *

FAA Pilot Certificate Number *

Education (Advise Diplomas and Degrees if any) *

Occupation *

Full-TimePart-Time

Employer *

Since *

Employer's Address *

Employer's Phone *

Percent of Work Time Spent on Non-Flying Duties *

Marital Status *

Number of Dependents *

FAA Pilot Certificates Now Held and Dates Obtained

Sport

Student

Since

Instructor

Class

Type of Aircraft

Other

Date of Last Logged Satisfactorily Accomplished Biennial Flight Review

Make and Model

Date of Last Logged Satisfactorily Accomplished Pilot Proficiency Exam

Make and Model

Date of Last Logged Satisfactorily Accomplished Instrument Proficiency Check

Make and Model

FAA Medical Certificate

FAA Medical

Medical Class

Expiration Date

Limitations (If none, type "NONE")0 / 180

FAA Basic Med

Exam Date

Online Course Completion Date

Sport

Valid U.S. Driver’s License Number

State

Training and Recurrent Training

Date of Last Biennial Flight Review or Equivalent

Date of Last Instrument Competency Check

Do you participate in the FAA Pilot Proficiency Awards Program?YesNo

If "yes" what have you completed?

Recurrent/Transition Courses: Describe and give dates of last courses attended

School/Instructor

Do you hold a current FSI Pro Card or Simuflite Card?YesNo

If "Yes," provide date

Pilot-In-Command Experience

Total Logged Pilot-In-Command Hours for All Aircraft *

Total Logged hours in All Aircraft *

ITEMIZED PILOT-IN-COMMAND HOURSItemize applicable pilot in command hours. Please list ALL classes that apply by clicking on the dropdown menu below.

Class *

This aircraft is insured on this policy.

Aircraft Make/Model *

Total Hours *

Total Last 12 Months

Total Last 90 Days

Instrument Last 6 Months

Co-Pilot Hours

Number of Water Landings & Takeoffs

Night vision device? Please call our office at (304) 876-3585.

Any person who knowingly and with intent to defraud any insurance company or other person who files an application for insurance containing any false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime.

Have you ever had an aircraft claim, incident or accident? *YesNo

Please explain in detail. *

Have you ever been cited or fined for violation of an aviation regulation? *YesNo

Please explain in detail. *

Has your pilot certificate ever been suspended or revoked? *YesNo

Please explain in detail. *

Have you ever been convicted of a felony or are you under indictment for a felony? *YesNo

Please explain in detail. *

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

Please explain in detail. *

Has your drivers license ever been suspended or revoked? *YesNo

Please explain in detail. *

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

Please explain in detail. *

Have you ever had or been treated for a chemical dependency? *YesNo

Please explain in detail. *

Are you regularly using any medication? *YesNo

Please explain in detail. *

Signature

Save as Draft

Requester Information

Pilot Details

FAA Pilot Certificates Now Held and Dates Obtained

FAA Medical Certificate

Training and Recurrent Training

Pilot-In-Command Experience

Downloadable Forms