Pilot History Form - The Hoxton AgencyThe Hoxton Agency

This pilot record is filed in connection with the Insurance Application of:*

Name*

First Last

Email*

Phone*

Address*

Street Address Address Line 2 City State ZIP Code

Birthdate*

FAA Pilot Certificate Number*

Occupation*

Employer*

Marital Status*

Number of Dependents*

FAA Pilot Certificates Now Held and Year Obtained

Student

Year Obtained

Private

Year Obtained

Commercial

Year Obtained

ATP

Year Obtained

CFI

Year Obtained

CFII

Year Obtained

MEI

Year Obtained

FAA Pilot Ratings Now Held and Year Obtained

ASEL

Year Obtained

AMEL

Year Obtained

ASES

Year Obtained

AMES

Year Obtained

Instrument

Year Obtained

Rotorcraft

Year Obtained

FAA Medical Certificate

FAA Medical
Basic Med
Sport

Medical Date

Medical Class

Date Last Online Aeromedical Course (Must have been within the last 2 years)

Date Last Physician's Visit (Must have been within the last 4 years)

Waivers (If none, type "none")*

Training and Recurrent Training

Date of last Biennial Flight Review or equivalent

Date of Last Instrument Competency Check (If not applicable, leave blank)

Do you participate in the FAA Pilot Proficiency Awards Program?

Yes
No

If "Yes," what phase 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?*

Yes
No

If "Yes," provide date

Pilot-In-Command Experience

Total Combined Flight Hours in All Aircraft*

Aircraft 1 Make/Model

Total Hours (Aircraft 1)

Total Last 12 Months (Aircraft 1)

Total Last 90 Days (Aircraft 1)

Aircraft 2 Make/Model

Total Hours (Aircraft 2)

Total Last 12 Months (Aircraft 2)

Total Last 90 Days (Aircraft 2)

Aircraft 3 Make/Model

Total Hours (Aircraft 3)

Total Last 12 Months (Aircraft 3)

Total Last 90 Days (Aircraft 3)

Aircraft 4 Make/Model

Total Hours (Aircraft 4)

Total Last 12 Months (Aircraft 4)

Total Last 90 Days (Aircraft 4)

Aircraft 5 Make/Model

Total Hours (Aircraft 5)

Total Last 12 Months (Aircraft 5)

Total Last 90 Days (Aircraft 5)

As pilot-in-command or as co-pilot have you had or been involved in any aircraft incidents or accidents?*

Yes
No