Aviation Activities Questionnaire Personal Information
Proposed Insured’s Legal Name (First, Middle Initial, Last) Email 1.
Date of Birth
Have you ever been issued a pilot’s license? a. If so, is most recent type:
Student
Yes Military
Private
Commercial
No
Transport
b. Date Issued? c. Was it issued subject to physical waiver? (If so, why?)
Yes
No
d. Date of last physical? e. Was physical: 2.
Class I
Class II
Class III
If your flying activity has ended: a. When? b. Why? c. Current ratings (Check all that apply.):
3.
IFR (Instrument Flight Rated) Other
CFI (Certified Flight Instructor)
d. Do you expect or contemplate renewal of flying activity in the next two (2) years?
Yes
No
Have you ever been grounded or had your license revoked?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
a. When?
Questions
b. Why? 4.
Have you ever served as a crew member other than pilot or co-pilot? If so, please describe.)
5.
Are you, or have you ever been, a military pilot or crew member? a. When? b. In what capacity? c. Do you now have any military aviation activity or obligation? (If so, please describe.) d. Date of last flight in military aircraft?
6.
Are you a member of any aviation organization? (If so, what?)
7.
Are you part or full owner of any type of aircraft? a. What type? b. Is maintenance regular and complete?
8.
How many total hours have you accumulated: a. As pilot or co-pilot? b. As crew member other than pilot?
GBU FINANCIAL LIFE
FL20-AV.2
WWW.GBU.ORG | NEWBUSINESS@GBU.ORG PO BOX 645949, PITTSBURGH, PA 15264-5257 412-884-5100 | 800-765-4428
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Aviation Activities Questionnaire (continued)
Questions (continued)
9.
If you have flown as a pilot, co-pilot, crew member, smoke jumper, aerial photographer, etc., within the past 24 months, or if you contemplate any such type of aviation activity in the future, please provide details of the nature and amount of activity: Hours Flown Past 24 Past 12 Months Months
Nature of Aviation Activity
Hours Estimate for Next 12 Months
Private flying, pleasure and/or business Scheduled airline Nonscheduled airline Company-owned plane Instructing Student Photography Crop treatment Charter, sight-seeing or air-taxi Forestry, traffic control or fish and game Inspection – pipe, power or telephone lines Experimental or testing Fire control Racing Stunting Other (Describe fully) Type of Plane Propeller Jet or turbojet Glider or Sailplane Helicopter Other (Describe fully) 10. Are hours listed above: From accurate record? Estimated? 11. If necessary to modify policy because of aviation, which of the following do you prefer? Aviation coverage with payment of appropriate extra premium; or, Coverage limiting amount payable if death results from participating in aviation I declare that all statements and answers to the foregoing questions are, to the best of my knowledge and belief, complete and true. I agree (a) that they shall form a part of my application; (b) that they shall be subject to the terms of the agreement found in the application; and, (c) that they shall become part of any policy based on my application.
Acknowledgement Fraud Warning. Any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of
claim or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree.
Signature of Proposed Insured or Guardian
FL20-AV.2
Date
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