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Pilot Demo

1General Information

2Pilot and Medical Certificate Information

3FAA Certificates and Ratings

4Flight & Ground Training Information

5Flight & Ground School Training Courses

6Pilot Flight Experience

7Make and Model Experience

8Underwriting Questions and Signature

Your Name*
First Middle Last
Email*
Email Confirm Email
Address
Street City State/Province Zip/Postal Code
Age*
Occupation
Professional Pilot?
- Yes
- No
Employed by
- Employee
- Contract Pilot
Named Insured
(for which this pilot form is to apply)
Make & Model
(of all aircraft to be flown for which this pilot form applies)

Pilot Certificate
Number
Limitations
Medical
Class
Date
Limitations
Waivers
Driver’s License
Number
State
State / Province / Region

Current Certificates and Ratings (check all that apply)
FAA certificate and rating
- Airline Transport
- Instrument
- CFI
- Tail Wheel (Conventional Gear)
- Commercial
- ASEL – Single Engine Land
- CFII
- Glider
- Private
- AMEL – Multi Engine Land
- MEI
- Flight Engineer
- Rotorcraft
- SES – Single Engine Sea
- Ground Instructor
- A & P Mechanic
- Light Sport Aircraft
- MES – Multi Engine Sea
- CFI Rotorcraft
- Other
Other
Type Ratings

Date of last completed Biennial Flight Review
Make and Model
Date of last completed Pilot Proficiency Exam
Make and Model
Date of last completed Instrument Proficiency Check
Make and Model

(1) Name & Location of School
Type of Air Craft
Date
Graduated
- Yes
- No
- Initial Training
- Recurrent Training
- Full Motion Simulator
- Non-Motion Simulator
- In-Aircraft Training
- Ground School
Special Certifications Completed
(2) Name & School Location
Type Of Aircraft
Date
Graduated
- Yes
- No
- Initial Training
- Recurrent Training
- Full Motion Simulator
- Non-Motion Simulator
- In-Aircraft Training
- Ground School
Special Certifications Completed

Enter Total Logged Pilot Hours for each Category Below
All Aircraft – Total Hours
Retractable Gear
Rotorwing – Total Hours
Pilot In Command – Total Hours
High Performance
Rotorwing Turbine – Total Hours
Last 12 Months – Total Hours
Turbo Prop
Tailwheel
Single Engine
Turbo Jet
Glider
Multi-Engine
CFI - Total Hours

List make & Model of Aircraft Flown Which Best Represents your Overall experience for which this Application is Made
Aircraft 1 Make & Model
Total Hours this aircraft
Last Training & Date
Total Hours this aircraft last 12 months
Aircraft 2 Make & Model
Total Hours this aircraft
Last Training & Date
Total Hours this aircraft last 12 months
Aircraft 3 Make & Model
Total Hours this aircraft
Last Training & Date
Total Hours this aircraft last 12 months
Aircraft 4 Make & Model
Total Hours this aircraft
Last Training & Date
Total Hours this aircraft last 12 months

ANSWER ALL QUESTIONS
FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance company, agent, or other person files an application for insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.
As a pilot in the last 5 years have you had an aircraft claim, incident, or accident?
- Yes
- No
As a pilot in the last 5 years have you been cited, penalized, disciplined, or fined for violation of any Civil or Military Air Regulations?
- Yes
- No
In the past 5 years has your pilot certificate or driver’s license been suspended or revoked?
- Yes
- No
Have you ever been arrested, convicted, or pleaded guilty for a felony.
- Yes
- No
Have you ever been convicted of, or are you under indictment in a legal action involving drugs or narcotics?
- Yes
- No
In the past 5 years have you been arrested or convicted for operating an automobile under the influence of alcohol or drugs.
- Yes
- No
Has any insurer cancelled or declined to renew any aircraft insurance for you?
- Yes
- No
Are you regularly using any medication not reported and approved by the FAA?
- Yes
- No
Explain fully each “Yes” answer (use separate page if necessary):
Answer
ALL OF THE INFORMATION HEREIN IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND I HAVE NOT KNOWLINGLY OR INTENTIONALLY CONCEALED OR MISTREPRESENTED ANY FACT. Note to the applicant: This pilot experience form may become part of the insurance application. Therefore all policy fraud terms and conditions may be applicable.
PILOTS SIGNATURE
Date

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The James A Gardner Company

Address: PO Box 680905 Marietta, GA 30052
Phone: 678-278-2100
Fax: 678-398-7038
Email: sales@jagardner.com

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