Pilot Resume Welcome to the Facer Insurance Agency
 
This pilot affiliated with: Policy #:
Pilot's Name: DOB:
Address: Marital Status:
City, ST, Zip: Phone:
Alternate Phone #: Email:
Occupation: Current Employer:
FAA Medical (Class and Date): Date Last Flight Review:
Highest FAA Pilot Certificate Held (e.g.Private, Commercial, ATP):
Check all ratings you hold:
  Single Engine Land Airplane Multi-Engine Land Airplane  
  Single Engine Instrument Multi-Engine Instrument  
  Rotor-Wing Rotor-Wing Instrument  
  Single Engine Sea Multi-Engine Sea  
  CFI CFII  
Type Rated in the following Aircraft
Where and When did you first learn to fly?

For the last 2 years, list every recurrent training facility you have attended.
Date Name of Facility Make and Model trained for
Do you hold a FlightSafety or Simu-Flite Pro Card?

ALL OF THE QUESTIONS BELOW SHOULD BE ANSWERED BASED ON HOURS YOU CAN VERIFY BY WRITTEN DOCUMENTATION (LOGBOOK COPIES, COMPANY FLIGHT RECORDS, ETC.)
 
Total Logged Hours Civilian: Total Logged Hours Military:
   
  Grand Total Last 12 Mo's   Grand Total Last 12 Mo's
Total Single Engine Fixed Gear: Total Tailwheel:
Total Retractable Gear: Total Multi-Engine:
Total Sea: Total Turbo-Prop:
Total Turbo-Jet:      
For what aircraft types do you request insurance to fly?
( please list make and model hours in parenthesis next to each make and model )
PLEASE EXPLAIN ALL YES ANSWERS ON REVERSE(Questions apply to the last 5 years). Yes No
1.Are you currently flying under any FAA waiver or limitation (don't report glasses)?
2.Have you been cited for any FAR violation?
3.As a pilot or aircraft owner, have you had an aircraft accident or incident?
4.As a pilot or aircraft owner, have you filed, or been party to filing, an aviation insurance claim?
5.Have you been convicted of any DUI or other substance abuse charge?
6.Have you been convicted of a felony or are you currently under indictment for a felony?
PILOT'S SIGNATURE:   DATE:
 
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Facer Insurance Agency, Inc.
Address: 554 Liberty Avenue, Rantoul, IL 61866
Mailing Address: P.O. Box 898, Rantoul, IL 61866
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