* = Required Information
Complete this Aviator questionnaire so we can help you now.
Full Name:
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Gender:
Male
Female
Date of Birth:
Home Address:
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Phone:
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Cell Phone
*
Best time to Call:
City:
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State
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Zip Code:
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Tobacco User:
Yes
No
Email
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Amount of Coverage:
Type of Coverage:
Years of Coverage:
Height:
Weight:
Prescriptions and dosages, if any:
1) In which of the following capacities do you fly: (check all that apply)
Aerial photography
Aerobatic
Airline Crew
Airline Pilot
Armed Services
Commercial Pilot
Construction work
Crop Spraying
Flight Instruction
Emergency Services
Helicopter Crew
Police work
Private Pilot
Racing
Stunt
Survey work Test Pilot
Other (Describe other)
2) FAA Certification: (check all that apply) Year first licensed
Student
Private
Commercial
Airline Transport Flight Instruction
Instrument Flight Rating
Date of Last Medical Renewal:
3) Do you anticipate your flying will be of a different nature in the future
Yes
No
If yes, please provide details:
4) Please provide the make and model of the aircraft(s) you usually fly:
5) Do you own or rent the airplanes you fly?
Own
Rent
6) Are you a member of a flying club?
7) What is the N Number of the airplane you fly?
8) Total lifetime hours of flight time:
Hours Flown Last 12 months:
Est. next 12 mo.
9) What airport is your home base?
10) Who is your Home Airport Fixed Based Operator?
Service Provided By:
Your Name:
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Your Agency:
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Phone:
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Email:
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Security Code
*