General Information
What is the name of the aircraft owner?
What is the pilot's name?
What is the pilot's date of birth?
MM slash DD slash YYYY
Please enter the email address for the person completing this form. *
What is the pilot's address?
What is the pilot's occupation?
Who is the pilot's employer?
What date was the pilot first employed by this employer?
MM slash DD slash YYYY
Pilot Certificates and Ratings
Which certificates and ratings are currently held by this pilot?
Please specify the rating and aircraft.
Pilot Information
Enter Airman's Certificate Number:
Enter the date this pilot was certified:
MM slash DD slash YYYY
Is this pilot a student?
What is the name of the instructor or FBO?
Enter the instruction airport location:
What is the date of this pilot's last medical certificate?
MM slash DD slash YYYY
What is this pilot's class of medical? (Not applicable for light sport aircraft.)
Does this pilot have any medical waivers?
Please provide an explanation for this pilot's medical waivers:
What is the date of this pilot's last biennial review?
MM slash DD slash YYYY
What type of aircraft was used in the biennial review?
What is the date of this pilot's last simulator instruction?
MM slash DD slash YYYY
What is the name of the manufacturer's ground and flight school this pilot attended?
What dates did this pilot attend the manufacturer's ground and flight school? (Ie. 3/2/19 to 4/2/19)
What is this pilot's AOPA membership #?
What is this pilot's EAA membership #?
Flying Experience
Please show flying experience in logged hours, do not group different aircraft of the same type in the category for the make and model on which approval is being sought. If hours cannot be substantiated by log books, please explain how hours have been verified/reconstructed.
Please select the aircraft types you have experience flying:
Single Engine Aircraft Experience
What is the make and model of the aircraft?
How many hours as pilot in command?
How many hours as co-pilot/dual instruction?
What was the total time?
What was the total time in the last 12 months?
What was the total time in the last 90 days?
Does this pilot have experience on another single engine aircraft?
What is the make and model of the aircraft?
How many hours as pilot in command?
How many hours as co-pilot/dual instruction?
What was the total time?
What was the total time in the last 12 months?
What was the total time in the last 90 days?
What was the total time on conventional gear?
What was the total time for all single engine aircraft?
Multi-Engine Aircraft & Jet Aircraft Experience
What is the make and model of the aircraft?
How many hours as pilot in command?
How many hours as co-pilot/dual instruction?
What was the total time?
What was the total time in the last 12 months?
What was the total time in the last 90 days?
Does this pilot have experience on another multi-engine aircraft or jet aircraft?
What is the make and model of the aircraft?
How many hours as pilot in command?
How many hours as co-pilot/dual instruction?
What was the total time?
What was the total time in the last 12 months?
What was the total time in the last 90 days?
What was the total time on multi-engine aircraft?
Seaplanes and Helicopters
What is the make and model of the aircraft?
How many hours as pilot in command?
How many hours as co-pilot/dual instruction?
What was the total time?
What was the total time in the last 12 months?
What was the total time in the last 90 days?
Does this pilot have experience on another seaplane or helicopter?
What is the make and model of the aircraft?
How many hours as pilot in command?
How many hours as co-pilot/dual instruction?
What was the total time?
What was the total time in the last 12 months?
What was the total time in the last 90 days?
What was the total time on seaplanes and helicopters?
Total Flying Experience
What is the grand total of all the experience this pilot has? (In hours)
Aircraft Accidents
Has this pilot ever been in an aircraft accident?
What was the location of the accident?
What was the date of the accident?
MM slash DD slash YYYY
What was the make and model of the aircraft that was involved in this accident?
Please enter any remarks about this accident below.
Is there another accident this pilot was involved in?
What was the location of the accident?
What was the date of the accident?
MM slash DD slash YYYY
What was the make and model of the aircraft that was involved in this accident? 2
Please enter any remarks about this accident below.
Additional Circumstances
Does this pilot have a physical impairment, waiver, limitation, or conditions on their medical or pilot certificate?
Please explain the circumstances around this:
Has an FAA, Transport Canada, Military Pilot or other similar Certificate held by this pilot been suspended or revoked?
Please explain the circumstances around this:
Has this pilot ever been cited for a violation of any aviation regulation in any country?
Please explain the circumstances around this:
Has this pilot ever been convicted of or pleaded guilty to a felony or driving while intoxicated?
Please explain the circumstances around this:
Disclaimer: This online questionnaire is a tool used to gather information. It is not an application for insurance. No insurance coverage will be bound or put into effect by submitting this form.
Consumer disclosure: By checking the box below you authorize the Agency who supplied this form to you to contact you via phone, email, and text messaging; to save and share with business partners the information you provided; to obtain consumer reports that may include credit-based reports (where legally allowed), public records, claims history, and driving records so that they can give you accurate insurance quotes.
