ࡱ> >` <bjbj 8?"LLLd8|b< /jjjjb!T"z#d.......$q1h3d.L%$,V'H$$l$###..&^###/%%%%  `t IMPORTANT: This Pilot History form becomes a legal part of your policy, and therefore it is mandatory that each question be answered as fully and truthfully as possible; any misstatement, misrepresentation or omission may make the policy invalid. Each pilot flying the aircraft to be insured must complete. PILOT TO COMPLETE THIS FORM USING BALL POINT OR TYPEWRITER. (ADD ADDITIONAL SHEETS AS NECESSARY) NAMED INSURED:  FORMTEXT       IAC Member #:  FORMTEXT        FORMCHECKBOX Owner Pilot  FORMCHECKBOX Flight Instructor  FORMCHECKBOX Named Pilot Name  FORMTEXT       Birth Date  FORMTEXT       Address  FORMTEXT       City  FORMTEXT       State  FORMTEXT       Zip  FORMTEXT       Certificate #  FORMTEXT       Date of FAA medical  FORMTEXT       Date of BFR  FORMTEXT       LICENSE:  FORMCHECKBOX Student  FORMCHECKBOX Sport  FORMCHECKBOX Recreational  FORMCHECKBOX Private  FORMCHECKBOX Commercial  FORMCHECKBOX Airline Transport  FORMCHECKBOX Mechanic A&P RATINGS:  FORMCHECKBOX SE Land  FORMCHECKBOX ME Land  FORMCHECKBOX Instrument  FORMCHECKBOX CFI  FORMCHECKBOX Glider  FORMCHECKBOX SE Sea  FORMCHECKBOX ME Sea  FORMCHECKBOX Rotorwing Do you hold an ICAS Aerobatic Competency Evaluation Certification?  FORMCHECKBOX No  FORMCHECKBOX Yes  Level  FORMTEXT       IAC Member #: _____________________ EAA Member #: _____________________ FLYING EXPERIENCE DATA: Total Time  FORMTEXT       hours Total hours Last 90 Days  FORMTEXT       hours Number of Competitions  FORMTEXT       Tail Wheel  FORMTEXT       hours Total Hours Past Year  FORMTEXT       hours Number of Airshows  FORMTEXT       Aerobatic  FORMTEXT       hours Aerobatic Dual Given  FORMTEXT       hours HOURS BY TYPE OF AIRCRAFT (for all aircraft being flown insured on this policy and / or other similar aircraft): Total Hours Hours Past 12 Months In Make & Model This Aircraft This Aircraft Notes or Comments  FORMTEXT      _________  FORMTEXT       hours  FORMTEXT       hours  FORMTEXT        FORMTEXT       _________  FORMTEXT       hours  FORMTEXT       hours  FORMTEXT        FORMTEXT      _________  FORMTEXT       hours  FORMTEXT       hours  FORMTEXT        FORMTEXT       _________  FORMTEXT       hours  FORMTEXT       hours  FORMTEXT        FORMTEXT       _________  FORMTEXT       hours  FORMTEXT       hours  FORMTEXT       IF ANY OF THE FOLLOWING ANSWERS ARE YES PLEASE GIVE FULL DETAILS: 1) Are you flying under any kind of a medical waiver or restriction?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 2) Have you ever been penalized, disciplined or fined for violation of Federal Aviation Regulations?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 3) Have you ever been convicted or pleaded guilty to a Felony?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 4) Have you ever been convicted or pleaded guilty of Drunken Driving?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 5) Have you ever been convicted or pleaded guilty to a Drug Charge?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 6) Have you taken or are you presently taking antidepressant drugs or tranquilizers?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 7) List ALL Violations, Suspensions, Accidents, Incidents, whether or not involving an insurance payment If None, STATE NONE, Do Not Leave Blank q t μުnZ?n*n)jhs5:CJOJQJU^JaJ5jhNhM5:CJOJQJU^JaJ&hNhI5:CJOJQJ^JaJ/jhNhI5:CJOJQJU^JaJ#h\hI:CJOJQJ^JaJ#hn+hm:CJOJQJ^JaJ#hmh:CJOJQJ^JaJ#hmhm:CJOJQJ^JaJhmhm:CJOJQJ^Jhmh:CJOJQJ^J"hmh5:CJOJQJ^J T V * , xf l "6$&gd  &dPgdm gd gdI$ a$gdI P&dPgdn+ gdm- l&$d%d&d'dNOPQgdx:  * , . 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Date Description Amount Paid  FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT       I affirm that the statements in the application are true to the best of my knowledge and belief, are made in good faith, and no Information has been withhold or suppressed which would adversely affect my pilot rating(s) or approval by the Insurer(s). Such Statements and answers will be the basis of any contract between me, the Insured and the Insurer(s) and shall be effective only if all statements and answers referred to above are full, complete and true on the date set forth herein. I hereby authorize the Insurer(s) or their agents to investigate any or all statements contained herein. I understand that this application does not commit the Insurer(s) to any liability whatsoever until the Insurer(s) agree to affect such Insurance coverages as have been applied for by this application. (Date) (Signature)       Northwest Insurance Group, Inc. 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