First Name *

Last Name *

Email *

Phone *

Date of birth *

Address *

City *

State *

Postal code *

Pilot Certificate Number *

Any other ratings or categories other than ASEL (AMEL, ASES, AGI, IGI, Rotorcraft, etc.)

AOPA Member # (if not a member, enter 0) *

Date of most recent flight review or successful practical test: *

Total flight time (hours) *

Total hours in the last 12 months *

Complex aircraft flight time (hours) *

High performance flight time (hours) *

Total C172 hours *

Total C172 Hours in last 12 months *

Total PA28R Hours *

Total PA28R Hours in last 12 months *

Total hours in A36 *

Total hours in A36 in last 12 months *

Medical Certificate or BasicMed *

First Class

Second Class

Third Class

BasicMed

Medical Certificate or BasicMed issue date: *

Please list any Medical Waivers/Limitations

Emergency Contact Name and Relationship *

Emergency Contact Phone Number *

In the past 5 years have you had an aircraft claim, incident or accident? If yes please enter what was the date of occurence, Total $ spent on the claim, and a brief description of the claim in the box at the bottom of this page. *

Have you ever been cited/fined for a violation of an aviation regulation? *

Has your pilot certificate ever been suspended or revoked? *

Has your driver's license ever been suspended or revoked? *

Have you ever been convicted of a felony? *

Have you ever had any arrest/conviction involving drugs/narcotics?

Have you ever been arrested for operating a motor vehicle recklessly?

Has any insurer ever canceled/non renewed your policy or coverage?

If you answered yes to any of the above questions, please briefly explain here.

For the insurance application: All of the information in this form is true and correct to the best of my knowledge and I have not knowingly or intentionally concealed or misrepresented any fact. This information will become part of the insurance application and as such all fraud statements are applicable. If you agree please type your full name below. *