Aircraft Operations Information Sheet - Texas
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16210 East Highway 290
Austin, TX 78723-1098
(800) 859-5995
FAX (800) 359-0650
AIRCRAFT OPERATIONS INFORMATION
Name of business _______________________________________________
Policy/Quote # _____________________________
Address ___________________________________________________________________________________________________
Description of business ______________________________________________________________________________________
AIRCRAFT INFORMATION
Year, make and model: ___________________________________________________________
___ Type: Single Engine (S), Multi-Engine (M), Rotor Wing ( R)
Number of passenger seats ______
Location of base/hangar_______________________________________________________________________________________
Typical annual flight hours _____________________________
Usual destinations ____________________________________
Average # of employee passengers at any given time ________
Use: Business % ________
Pleasure % ________
Is aircraft used for fire fighting, crop dusting, seeding, banner towing, spraying, pipeline inspection, sky writing, power line inspection,
exploration, racing, endurance tests or stunt flying? Yes_____
No ______ If yes, explain _______________________________
___________________________________________________________________________________________________________
PILOT INFORMATION
Name of pilot in command ____________________________________________________
st
nd
rd
Pilot Medical Certification:
_____ 1
Class
_____2
Class
_____ 3
Class
Total flying hours _______________________________________
Total hours in make and model listed above ______________
Total flying hours within last 12 months _________________
Pilot’s age __________________________________________
Full-time professional pilot?
Yes_____
No ______
If not a full-time professional pilot, list job title and duties: _____________________________________________________
Has pilot been involved in any aircraft incidents/accidents in the past 5 years?
Yes_____
No ______
If yes, discuss where, when and why the incident or accident occurred: __________________________________________
___________________________________________________________________________________________________
Has pilot been convicted of any DWI offense in any motor vehicle in the past 5 years?
Yes_____
No ______
If yes, explain ______________________________________________________________________________________
Name of other pilot __________________________________________________________
st
nd
rd
Pilot Medical Certification:
_____ 1
Class
_____2
Class
_____ 3
Class
Total flying hours _______________________________________
Total hours in make and model listed above ______________
Total flying hours within last 12 months __________________
Pilot’s age __________________________________________
Full-time professional pilot?
Yes____
No ______
If not a full-time professional pilot, list job title and duties: ____________________________________________________
Has pilot been involved in any aircraft incidents/accidents in the past 5 years?
Yes_____
No ______
If yes, discuss where, when and why the incident or accident occurred: __________________________________________
___________________________________________________________________________________________________
Has pilot been convicted of any DWI offense in any motor vehicle in the past 5 years?
Yes_____
No ______
If yes, explain ______________________________________________________________________________________
Signature ______________________________________________________________
Date _____________________________
rev. 11/05
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Parent category: Business