July 18, 2019
Coming Soon!

Pilot History Form

Conour Insurance, Inc. | 2075 Columbiana Road Suite 1 Birmingham, AL 35216

Phone: (205) 822-7020 | Toll Free: (855) 755-2013 | Fax: (855) 755-7713

Contact Information
Name of Aircraft Owner or Name of Insured: *
Pilot's Full Name: *
Pilot's Address:
City:
State/Province:
Zip/Postal Code:
Your current age:
Email *
Phone: *
Employment History
  Employer Dates Employed Occupation: If employed as a pilot, list all duties in addition to those normal for a pilot and indicate percentage of your total time spent on non-pilot related duties.
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Certificates, Endorsements and Ratings (Canadian Only)
Please check the boxes that apply: Student
Private
Commercial
Airline (ATP)/(ATR)
Instructor
Instrument Rating
Helicopter
Mechanic Aircraft
Single Engine Land
Single Engine Sea
Seaplane
Multi-Engine Land
Multi-Engine Sea
Center Line Thrust
Glider
Mechanic Powerplant
Other
Type Ratings/Endorsements (Specify):
Civilian - Total Hours - Logged
  Piston - Land Piston - Sea Piston - Amph. Turbo Prop. Jet
Single Eng Fixed Wing
Multi Eng Fixed Wing
Rotary Wing
Military - Total Hours - Logged
  Piston Turbo Prop. Jet
Fixed Wing
Rotary Wing
Medical Class and Date of Expiration
Medical Class/Date of Expiration:
Date of Last Biennial or Annual Flight Review
Date:
Breakdown of Experience By Make and Model
(Please specify makes and models whether land, sea, or amphibian)
  List Make and Model (One per line - must include make and model aircraft being insured) Total Hours Last 90 Days VFR Last 12 Months IFR Last 12 Months
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Experience Continued
Total Logged Hours for Tailwheel Equipped Aircraft:
Total Pilot-In-Command Hours of all Multi-Engine Aircraft:
Approximate Number of Water Landings and Take-offs Made During the Last 12 Months:
Where and when did you learn to fly? (Give year, place and school or course completed):
Specify make and model(s) on which approval is sought as:
Pilot-In-Command:
Second-In-Command:
List manufacturer's approved, initial ground & flight schools and dates attended (specify by model)
  School Model Dates
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If you are not currently enrolled in a recurrent flight training program, please complete:
Complete the following with respect to your most recent flight proficiency check flight in the insured aircraft make and model
Was it: VFR  IFR
Date:
Name of Facility Providing Proficiency Check Flight:
Are you or your company enrolled in any recurrent flight training program?
Are you or your Company Enrolled? Yes  No
If yes, specify make and model aircraft, the facility affording the training, their location and number of recurrent training programs completed annually by you:
Do you have any physical impairments, waivers, limitations or conditions on your med. certificate?
Yes or No? Yes  No
If yes, please explain:
Has your FAA or DOT or Military Pilot Certificate ever been suspended or revoked?
Yes or No? Yes  No
If yes, please explain:
Violation Citations
Have you ever been cited for any violations of Federal or Canadian Air Regualtions or any license limitations? Yes  No
If yes, please explain:
Motor Vehicle Violations
Arising out of the operation of a motor vehicle, have you ever had your driver's license suspended or revoked? Yes  No
If yes, please explain:
Have you ever been convicted of or pleaded guilty to a charge of reckless driving or driving under the influence of alcohol or drugs? Yes  No
If yes, please explain:
Declined aircraft hull or liability insurance?
Have you ever had an application for aircraft hull or liability insurance declined by an insurance company? Yes  No
If yes, please explain:
Have you ever had any aircraft accidents/incidents while acting as pilot?
Yes or No? Yes  No
If yes, give dates, make and model of aircraft, and details of accident(s):
Have you filed any aviation claims in the last three years?
Yes or No? Yes  No
If yes, give dates and brief summary of circumstances:
* = Required Field