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Pilot Experience Form
Step 1 of 2: Please enter your pilot information in the form fields and then click the button below:
Aviation Marine Insurance Services, Inc.
5707 Redwood Road, Oakland CA 94619
Tel 800-972-0907 Fax 888-945-1230
Who are you flying for?
Pilot First Name
Last Name
Pilot Email
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Pilot's Address - Street
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Airman Number
Occupation
Employer
Time with Employer
Last Medical
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Medical Class
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Pilot Ratings
Private
Commerical
Instrument
CFI
CFII
MEI
ATP
IA
AP
Aircraft Ratings
SEL
MEL
SESea
MESea
Tailwheel
AerialApp
Rotor
Aircraft Type Ratings (12,500 lbs and over)
Total Fixed Wing Hours
Total Time:
PIC:
Last 12 Mo:
PIC Multi-Eng:
PIC Turbo-Prop:
PIC Jet:
SIC Jet:
Tailwheel:
Retract:
Total Rotor Wing Hours
PIC:
Last 12 Mo:
PIC Piston:
PIC Turbine:
PIC Turbine-Multi:
Time in Relevant Makes & Models
Make & Model
PIC Time
SIC Time
Last School Name
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Yes/No Questions
Correct Answer
Please explain "Yes" answers
Do you have any physical impairments
or are you flying under a waiver?
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Yes
No
Have you ever been penalized for a FAR violation?
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Yes
No
Have you ever had an aviation accident or incident?
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Yes
No
Have you ever been convicted of a DUI or Felony
or had your drivers license suspended?
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Yes
No
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