AVIATION QUESTIONNAIRE
Name___________________________________________________ Date of birth______________________________
1. Hours flown as a PILOT or COPILOT
Contemplated Past 12 One to Two Contemplated Past 12 One to Two Years
TYPE OF FLYING Next 12 Months Years Ago TYPE OF FLYING Next 12 Months Ago
Months Months
Commercial (flying for pay) Non- commercial (not flying for pay)
Scheduled passenger Pleasure
airlines
Employer owned aircraft Personal business
transportation
Nonscheduled or charter Instruction as a
student
*Crop dusting or aerial Other (describe under
spaying (Answer 13. below)
question 9 below)
Student Instruction
Exhibition or Stunt Flying **Military (Answer
question 11. below
Other (describe under
13. below)
2. Total numbers hours flown as a pilot _________ 3. If not a Pilot, specify capacity in which you fly, e.g. passenger, 4. Date of last flight.
etc. ____/____/____
5. a. What type of certificate license do you have? Student If “Student” when did you first obtain Students Pilot’s Certificate? _______________
Month/Year
Private Commercial ATR Other (specify)
b. Do you have an Instrument Flight Rating (IFR): Yes No c. What other ratings do you have?
d. Class of FAA medical certificate held? e. Date of last FAA medical examination? ___________________ Month Year
f. Does your FAA medical certificate specify any operational limitations or any limit on duration? Yes No (if “Yes” give details below)
YES NO
COMPLETE QUESTIONS 6. THRU 10. WITH RESPECT TO CIVILIAN FLYING GIVING DETAILS TO “YES” ANSWERS BELOW
6. Do you use a Public Airport?
7. Have you flown or do you intend to fly outside the United States?
8. Have you flown or do you intend to fly Prototype, Experimental, or Personally Built Aircraft, Rotorcraft, Balloon, or gilders?
*9. If an aerial applicator, do you fly an aircraft specifically and primarily built for aerial application (New Generation Aircraft)?
If so, what make, model and year is this aircraft? What percentage of application is done in this plane? __________________%
10. Have you engaged or do you contemplate engaging in any type of flying not indicated above?
*11. Please answer questions a. through g. with respect to MILITARY FLYING
a. To what military organization do you belong?
b. Date of last flight (month and year)
c. In what type of aircraft do you fly? (e.g. B58 Supersonic Jet Bomber)
d. Do you fly into war zones? If so where?
e. How long have you been flying in this type of aircraft? (if less than 1 year, also specify aircraft previously flown)
f. Do you ever fly from an aircraft carrier? Yes No g. If not a pilot, specify in what capacity in which you fly, e.g. navigator.
12. If you should be given a choice of either of the following underwriting actions, which would you prefer?
a. To pay an additional premium for coverage unrestricted as to aviation activities b. To have an aviation exclusion endorsed on the policy.
13. DETAILS (specify question numbers)
I represent that all statements and answers to the above questions are complete and true to the best of my knowledge and belief.
Signature of Proposed Insured____________________________________________________________ Date_______/_______/_______
Witness______________________________________________________________________________ Date_______/_______/_______
