Providing Aviation Insurance for More Than 26 Years - Carrio Aviation Insurance - 800.344.4359
 
 
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Pilot Qualifications Insurance Application

Middle Initial:
State: Zip:
Date of Birth Education:


Show percent of work time spent on non-flying duties: %
Employed by: Since: Full or Part Time?
State: Zip:
List previous employers and position for last 5 years:
Airman Certificate Number Medical:
Number: Class:
Limitations: Expiration Date: Limitations:

Current Certificates and Ratings

Student:

Since:
Private:  
Commercial:  
Sr. Commercial:  
Airline (ATP):  
Instructor: Class:
Instrument: Class:
Night:  
Single-Engine - Land:  
Single-Engine - Sea:  
Center Line Thrust:  
Multi-Engine - Land:  
Multi-Engine - Sea:  
Type rated in: Type:
Rotocraft:  
Glider:  
A&P Mechanic:  
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:

Flight and Ground School Training Courses:

Name & Location of School
Type of Aircraft
Date
Graduated?
Type Training:
Name & Location of School
Type of Aircraft
Date
Graduated?
Type Training:

Aerial Applicator:
Number of years experience as an aerial applicator pilot:
Total hours applying Herbicides:
Total Hours applying Insecticides:
List states you are currently licensed to conduct aerial application:
Explain any suspension or revocation of any state aerial applicator certificate held by you:

Logged Pilot Hours
Total Pilot-In-Command hours for all aircraft:

Class Make & Model Total Last 90 Days Last 12
Months
Instrument
6 months
Co-Pilot
Hours
Insured Make & Model
Single-Engine
Fixed Gear
 
Singe-Engine
Retractable
 
Multi-Engine Piston
 
Turbo-Prop
 
Jet
 
 
Helicopter-Recip
Helicopter-Turbine
Helicopter-Sling Load
Number of Water Landings & Takeoffs

---ANSWER ALL QUESTIONS---
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.

1. Have you ever had an aircraft claim, incident or accident?
2. Have you ever been cited or fined for violation of an aviation regulation?
3. Has your pilot certificate ever been suspended or revoked?
4. Have you ever been convicted of a felony or are you under indictment for a felony?
5. Have you ever been convicted of driving a motor vehicle under the influence of alcohol or narcotics, or of reckless driving?
6. Has your driver’s license ever been suspended or revoked?
7. Have you ever been convicted of or are you under indictment in a legal action involving drugs or narcotics?
8. Have you ever had or been treated for a chemical dependency?
9. Are you regularly using any medication?

Explain fully each “Yes” answer:

All of the information herein is true & correct to the best of my knowledge and I have not knowingly or intentionally concealed or misrepresented any fact. This form will become part of the insurance application and as such all fraud statements are applicable.

By typing your name here you agree to apply for Pilot Qualifications Insurance:

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