Pilot Information for Insurance Roster
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This field is for validation purposes and should be left unchanged.
Name
(Required)
First
Last
Birthdate
(Required)
MM slash DD slash YYYY
AOPA Member?
(Required)
Yes
No
Individual Renters Insurance
(Required)
Do you have a Renters Insurance policy that would cover damage to the aircraft?
Yes
No
Valid FAA Certificates / Ratings Held
(Required)
Student
Private
Commercial
Instrument
Multi
ATP
CFI
Recreational
Sport
CFII
MEI
MEII
RotorWing
Single Engine Sea
Multi Engine Sea
Lighter Than Air
Glider
Remote Pilot
Total Flight Time
(Required)
Retract Gear Time
(Required)
Multi-Engine Time
(Required)
Tailwheel Time
(Required)
Last 90 Days
(Required)
Last 12 Months
(Required)
Make/Model Time (C150/152)
(Required)
Make/Model Time (C172)
(Required)
Make/Model Time (C182)
(Required)
Medical Date
(Required)
MM slash DD slash YYYY
Flight Review Date
(Required)
MM slash DD slash YYYY
Accidents, Restrictions, and Waivers
(Required)
Have you had any accidents, have Restrictions, or Waivers?
Yes
No
If you indicated "Yes" to Accidents, Restrictions or Waivers, please describe
Occupation or Business
(Required)
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