Navigating through the complexities of pilot insurance applications can be an intricate process, demanding meticulous attention to detail. The Usaig Pilot Record Form serves as a cornerstone in this procedure, requiring comprehensive information that ranges from basic personal details to specific pilot credentials and experience. It starts with essential personal information, including name, address, and marital status, before delving into the nitty-gritty of pilot certification—listing various FAA Pilot Certificates and Ratings alongside their issuance dates. This form doesn't stop at just cataloging certificates; it digs deeper into a pilot's flying history, requesting data on first solo flights, type ratings, and recent proficiency checks. Moreover, the form inquires about participation in the WINGS - Pilot Proficiency Program, which is indicative of a pilot's ongoing commitment to safety and skill improvement. In addition to personal flying history, the form addresses legal compliance and health status, querying about possible Federal Aviation Regulations violations, medical certificate limitations, and even driving history, considering how these factors might influence a pilot's eligibility for insurance. This comprehensive document is a testament to the insurance industry's meticulousness in assessing risk—a collection of legal notices tailored to various states underscores the seriousness with which fraudulent or misleading information is treated. As such, the Usaig Pilot Record Form is not merely a formality but a critical step in the careful dance between pilots seeking coverage and the insurance entities evaluating their risk, ensuring that every flight taken is backed by a robust safety net of accurate and truthful information.
| Question | Answer |
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| Form Name | Usaig Pilot Record Form |
| Form Length | 3 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 45 sec |
| Other names | usaig f104, usaig pilot form, usaig pilot record, usaig pilot records |
PILOT RECORD FORM
Name:
Street Address:
City: |
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State: |
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Zip: |
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Birth Date: |
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Marital Status: |
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Number of Dependents: |
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Occupation: |
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Pilot Certificate Number: |
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Employer: |
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FAA Pilot Certificates and FAA Pilot Ratings Now Held and Date Obtained |
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Certificate |
Date |
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Rating |
Date |
Other Certificates or Ratings |
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Student |
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ASEL |
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Sport |
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AMEL |
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Private |
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Instrument |
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Commercial |
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Rotorcraft |
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ATP |
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Seaplane |
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Flight Instructor |
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Glider |
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FAA Medical Certificate |
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Date Issued: |
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Class: |
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Any physical impairments or limitations or waivers on Medical Certificate? |
Yes |
No |
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Please explain if “Yes:” |
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Training and Recurrent Training |
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Year of first solo flight: |
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Type rated in the following aircraft: |
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Date of last Flight Review or equivalent: |
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Date of last instrument proficiency check (IPC) in the insured aircraft: |
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Do you participate in WINGS - Pilot Proficiency Program? |
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Yes |
No |
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If “Yes,” what level have you completed? |
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Basic |
Advanced |
Master |
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What phase number? |
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Date Completed: |
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Initial/Recurrent/Transition Courses: |
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Name of Facility |
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Make and Model |
Date Attended |
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Do you hold a current FSI Pro Card or SimuFlite Card?
Yes
No |
If “Yes,” date: |
By Make/Model |
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of Aircraft |
Total Hours |
Total Last 12 Months |
Total Instrument |
Total Night |
All Single Engine |
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All Multi Engine |
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All Turboprop |
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All Turbojet |
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All Helicopter |
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All Seaplane/Amphib |
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Glass Cockpit/G1000 |
Not Applicable |
Total
By Make/Model |
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of Aircraft |
Total Hours |
Total Last 12 Months |
Total Instrument |
Total Night |
All Single Engine |
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All Multi Engine |
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All Turboprop |
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All Turbojet |
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All Helicopter |
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All Seaplane/Amphib |
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Glass Cockpit/G1000 |
Not Applicable |
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Total |
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accidents? |
Yes |
No |
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As |
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Regulations violations or have your pilot privileges ever been suspended or revoked? |
Yes |
No |
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Has your automobile driver’s license ever been suspended or revoked? |
Yes |
No |
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Have you ever been arrested for operating an automobile under the influence of alcohol or |
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drugs? |
Yes |
No |
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Have you had any automobile accidents within the last five years?
Yes
No
Use this space for explaining “Yes” answers to previous questions.
NOTICE TO ARKANSAS APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit, or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
NOTICE TO COLORADO APPLICANTS: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Authorities.
NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.
NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud or deceive any insurance company files a statement of claim containing any false, incomplete or misleading information is guilty of a felony in the third degree.
NOTICE TO KENTUCKY APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime.
NOTICE TO LOUISIANA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit, or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
NOTICE TO MAINE APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.
NOTICE TO MARYLAND APPLICANTS: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
NOTICE TO NEW JERSEY APPLICANTS: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.
NOTICE TO NEW MEXICO APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit, or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.
NOTICE TO NEW YORK APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.
NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
NOTICE TO OKLAHOMA APPLICANTS: WARNING: Any person who knowingly and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
NOTICE TO OREGON APPLICANTS: Any person who makes an INTENTIONAL MISSTATEMENT that is MATERIAL TO THE RISK MAY BE found guilty of insurance fraud by a court of law. In order for an insurer to deny a claim on the basis of misstatements, misrepresentations, omissions or concealments on the part of the insured, the insurer must show that the misinformation is material to the content of the contract, that the insurer relied upon the misinformation AND that the information was either material to the risk assumed by the insurer OR that the misinformation was provided fraudulently.
NOTICE TO PENNSYLVANIA APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.
NOTICE TO RHODE ISLAND APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
NOTICE TO TENNESSEE APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
NOTICE TO VIRGINIA APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
NOTICE TO WASHINGTON APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
NOTICE TO WEST VIRGINIA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for a payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
I represent that the answers given are true and complete to the best of my knowledge and belief and that no material information has been withheld.
Date:Signed:
This pilot record is filed in connection with the Insurance Application of :