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PILOT QUESTIONNAIRE
1
Personal Particulars
2
Flying Licenses Held
3
Aircraft Hours
4
NTCA Hours
5
Total Hours Logged by Type
6
Older than 65 complete
7
Accident History
8
Other Information
9
Privacy Clause & Declaration
Personal Particulars
Surname
First Name(s)
Date of Birth
DD slash MM slash YYYY
ID/Passport No
Occupation
Address:
Cellphone No
Email Address
(Required)
Flying Licenses Held
Type of License
License Number
Expiry Date
DD slash MM slash YYYY
Instrument Rating
Yes
No
Instructors’ ratings (eg. Grade1)
No
Grade I
Grade II
Grade III
Test Pilot Ratings
Yes
No
Night Rating
Yes
No
Safety Pilot Rating
Yes
No
Tug Pilot rating
Yes
No
Restrictions
Attach copy of Pilot License
Drop files here or
Select files
Accepted file types: jpg, gif, png, pdf, Max. file size: 256 MB, Max. files: 2.
Form completed for Aircraft Reg:
(Required)
Total Hours Logged in Conventional Powered Aircraft
(excluding Microlight/Ultralight Aircraft and Powered Gliders)
Fixedwing Aircraft
All Single Piston-engined - PIC
All Single Piston-engined - Dual
All Single Piston-engined - Co-Pilot
All Multi Piston-engined - PIC
All Multi Piston-engined - Dual
All Multi Piston-engined - Co-Pilot
Single Turbine/turboprop - PIC
Single Turbine/turboprop - Dual
Single Turbine/turboprop - Co-Pilot
Multi Turbine/turboprop - PIC
Multi Turbine/turboprop - Dual
Multi Turbine/turboprop - Co-Pilot
Jet - PIC
Jet - Dual
Jet - Co-Pilot
Fixedwing Aircraft PIC Total
Fixedwing Aircraft Dual Total
Fixedwing Aircraft Co-Pilot Total
Fixedwing Aircraft GRAND TOTAL
Retractable Gear - PIC
Retractable Gear - Dual
Retractable Gear - Co-Pilot
Tail Wheel - PIC
Tail Wheel - Dual
Tail Wheel - Co-Pilot
Rotorwing Aircraft
All Single Piston-engined - PIC
All Single Piston-engined - Dual
All Single Piston-engined - Co-Pilot
All Multi Piston-engined - PIC
All Multi Piston-engined - Dual
All Multi Piston-engined - Co-Pilot
Single Turbine/turboprop - PIC
Single Turbine/turboprop - Dual
Single Turbine/turboprop - Co-Pilot
Multi Turbine/turboprop - PIC
Multi Turbine/turboprop - Dual
Multi Turbine/turboprop - Co-Pilot
Jet - PIC
Jet- Dual
Jet - Co-Pilot
Rotorwing Aircraft PIC Total
Rotorwing Aircraft Dual Total
Rotorwing Aircraft Co-Pilot Total
Rotorwing Aircraft GRAND TOTAL
The above hours should exclude Simulator hours
Simulator hours
Total Hours Logged in Microlight/Ultralight Aircraft, Powered Gliders and non-Powered Gliders
Microlight / Ultralight
3-Axis - PIC
3-Axis - Dual
Weight Shift - PIC
Weight Shift - Dual
Gyrocopter - PIC
Gyrocopter - Dual
Microlight / Ultralight TOTAL
Powered Gliders
3-Axis - PIC
3-Axis - Dual
Weight Shift - PIC
Weight Shift - Dual
Gyrocopter - PIC
Gyrocopter - Dual
Powered Gliders TOTAL
Non-powered Gliders
3-Axis- PIC
3-Axis - Dual
Weight Shift- PIC
Weight Shift - Dual
Gyrocopter- PIC
Gyrocopter - Dual
Non-powered Gliders TOTAL
Total Hours Logged by Type
Aircraft Make & Model 1
Total Hours PIC
Total Hours Dual
Total Hours Co-Pilot
Total Hours
Past 60 days
Aircraft Make & Model 2
Total Hours PIC
Total Hours Dual
Total Hours Co-Pilot
Total Hours
Past 60 days
Aircraft Make & Model 3
Total Hours PIC
Total Hours Dual
Total Hours Co-Pilot
Total Hours
Past 60 days
If you are 65 years of age or older, please complete this Section
Total Hours flown, as Pilot/Co-Pilot, in the past 12 months:
Number of landings performed, as Pilot/Co-Pilot, in the past 12 months:
Previous Accident/Incident/Violation History
Please give details below of any Accidents, Incidents or Violations involving any aircraft in which you were acting as Pilot-inCommand or Co-Pilot, or whilst you were flying Dual, including whilst you were under (or giving) instruction, during the 60 months immediately preceding the current date. Give the following details for each, using a separate sheet if necessary. For the purpose of this declaration:
Accident/Incident has the meaning specified in Part 1.01.1 of the Civil Aviation Regulations 2011 Violation means a breach of aviation rules, regulations or other conditions for which an official sanction has been issued by any civil aviation authority
Specify whether Accident, Incident or Violation
Date of Accident, Incident or Violation
DD slash MM slash YYYY
Aircraft Make, Model & Reg No
Owner of Aircraft
Purpose of Use at the Time of the Accident, Incident or Violation
Extent of Damage or Nature of Violation
Cost of Repairs (if applicable)
Official Cause of Accident/Incident, or your opinion of probable cause if no official finding was made at the time or subsequently
Other Information
Please specify any other information that you believe Insurers should be aware of in relation to your flying experience or flying ability (such as military or nonpowered flying experience, flying awards received, etc.) taking into account the Warning on the first page of this Questionnaire and the Declaration as noted below.
Privacy Clause
We care about the privacy, security and online safety of your personal information and we take our responsibility to protect this information very seriously. In order to provide you with insurance, we have to process your personal information. We will share your personal information with other insurers, industry bodies, credit agencies and service providers. This includes information about your insurance, claims and premium payments. We do this to provide insurance services, prevent fraud, assess claims and conduct surveys. For more information, please read our official Privacy Policy on our website
Declaration
Consent
I hereby declare that, to the best of my knowledge and belief, the particulars and answers contained in this Questionnaire are true, complete and correct and that I have not withheld any information that I believe would change a reasonable person’s opinion of my flying experience or flying ability.
Signature
(Required)
Date
(Required)
DD slash MM slash YYYY
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