AvPac Pilot History Form

Complete form in entirety filling in all blanks. Then sign and date at the bottom of the form.

GENERAL INFORMATION

Pilot's Name*:

Street Address:

City, State, Zip:

Phone Home:

Phone Cell*:

Work:

DOB:

Email address*:

Employer:

Named Insured:

LICENSE / RATINGS

Pilot:
Student PilotPrivate PilotCommercial PilotAirline Transport PilotCert. Flight InstructorFull Time Pro PilotInstrumentMulti-Engine LandRotor Wing

Date you obtained your Ratings Instrument:

Date you obtained your Ratings Multi-Engine:

FAA Certificate Numbe:

PILOT EXPERIENCE / LOGGED FLIGHT HOURS (TOTALS)

Aircraft Make/Model to be Insured:

Total Time Logged:

Pilot In Command:

Total Time Insured Model:

Last 12 Months (Model):

Last 90 days (Model):

Multi-Engine:

Retractable Gear:

Tail Wheel:

Instrument:

Date of Last BFR:

Turbo-Prop SIC:

Turbo-Prop PIC:

Turbo-Jet SIC:

Turbo-Jet PIC:

Rotary Wing:

Turbine Rotary Wing:

Last 12 Months (All A/C):

Last 90 days (All A/C):

Class of Current Medical:

Date of Last Medical:

Last Training for Model Specific Date:

Last Training for Model Specific Place:

Other Aircraft Experience / School with Times:

Type Ratings Obtained (list all):

QUESTIONS: (Type YES or NO and give explanation for YES answers)

Have you ever had an aircraft Accident, Incident or Violation? (If YES, give explanation)

Has your driver's license every been suspended or revoked? (If YES, give explanation)

Have you ever been convicted of driving a motor vehicle under the influence of alcohol or narcotics? (If YES, give explanation)

Have you ever been penalized for a FAR violation? (If YES, give explanation)

Have you ever been convicted of, or are you under indictment in a legal action involving drugs or narcotics? (If YES, give explanation)

Are you flying under a waiver? (If YES, give explanation)

Has any insurance company and/or Underwriter ever cancelled, nonrenewed, or declined coverage on your behalf? (If YES, give explanation)

FURTHER EXPLAIN "YES" ANSWERS HERE: (Attach another sheet if more space is needed)

By signing below I warrant the truth of my responses and that nothing material has been withheld or suppressed.

Person completing this form:

Date of Signature:

Signature: