The Go Around ClubBaton Rouge · KBTR

Insurance · Pilot record

Pilot record for insurance

Every member must be approved by the club's aviation insurance before flying N542W. Fill this out once — we'll put your answers onto the insurer's official Pilot Record form for you.

Your information is sent privately to the club and used only for insurance approval.

01

About you

02

Pilot licensing

Check all that apply.

03

FAA pilot ratings

Check all that apply.

04

Logged flight hours

Enter numbers only. Leave blank if zero or not applicable.

05

Aircraft & training

Aircraft you currently fly or are seeking insurance approval for — we've added the club's airplane for you.

Aircraft 1
Aircraft 2
Aircraft 3
Aircraft 4
06

Medical & currency

Last medical

Last flight review

Last instrument proficiency check

07

Additional information

As pilot, any incidents, accidents; any citations for FAR violations or license limitations?

Any felony convictions or license suspensions arising out of operation of a motor vehicle?

Any arrests/convictions for operation of a motor vehicle recklessly or under influence of alcohol or drugs?

Has any insurance co. or underwriter cancelled, declined or non-renewed any insurance on your behalf?

08

Sign

I represent that the answers given are true and complete to the best of my knowledge and believe that no material information has been withheld.