Student:
Flight and Ground School Training Courses:
Logged Pilot Hours Total Pilot-In-Command hours for all aircraft:
---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? Choose One: Yes No 2. Have you ever been cited or fined for violation of an aviation regulation? Choose One: Yes No 3. Has your pilot certificate ever been suspended or revoked? Choose One: Yes No 4. Have you ever been convicted of a felony or are you under indictment for a felony? Choose One: Yes No 5. Have you ever been convicted of driving a motor vehicle under the influence of alcohol or narcotics, or of reckless driving? Choose One: Yes No 6. Has your driver’s license ever been suspended or revoked? Choose One: Yes No 7. Have you ever been convicted of or are you under indictment in a legal action involving drugs or narcotics? Choose One: Yes No 8. Have you ever had or been treated for a chemical dependency? Choose One: Yes No 9. Are you regularly using any medication? Choose One: Yes No 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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