Pilot Experience Form

Current Certificates and Ratings (check all that apply)

Enter Total Logged Pilot Hours for each Category Below

List make & Model of Aircraft Flown Which Best Represents your Overall experience for which this Application is Made

Explain fully each “Yes” answer (use separate page if necessary):

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.