ࡱ> jli @ Jbjbj (fS r r r 8 T v<<<<jl$:R!pQ<<>R<<< g?/r ^4T0!xUPt#t# r Rr  THE SCHANTZ AGENCY & T.H.E. INSURANCE COMPANY PILOT INFORMATION Pilot Name: FORMTEXT      Phone:  FORMTEXT      Street Address: FORMTEXT      E-Mail: FORMTEXT      City, State, Zip:  FORMTEXT      Pilot License Number:  FORMTEXT      Date of Birth:  FORMTEXT      Limitations:  FORMTEXT      No. of Years Flying:  FORMTEXT      Date of Last Biennial:  FORMTEXT      Total Hours Flown as PIC:  FORMTEXT      Drivers License Number:  FORMTEXT      Number of Hours Last 12 Months:  FORMTEXT      Have you attended a Safety Seminar in Last 12 Months:  FORMCHECKBOX  Yes  FORMCHECKBOX  No. If Yes, please enter Seminar name and date:  FORMTEXT      Total Hours As PIC in AX6 (2 Passengers)  FORMTEXT      Total Hours Last 12 Months:  FORMTEXT       Total Hours Est. Next 12 Months  FORMTEXT      Total Hours As PIC in AX7 (3 Passengers)  FORMTEXT      Total Hours Last 12 Months:  FORMTEXT       Total Hours Est. Next 12 Months:  FORMTEXT      Total Hours As PIC in AX8B (4 Passengers)  FORMTEXT      Total Hours Last 12 Months:  FORMTEXT       Total Hours Est. Next 12 Months:  FORMTEXT      Total Hours As PIC in AX8 (5 Passengers)  FORMTEXT      Total Hours Last 12 Months:  FORMTEXT       Total Hours Est. Next 12 Months:  FORMTEXT      Total Hours As PIC in AX9 (6 Passengers)  FORMTEXT      Total Hours Last 12 Months:  FORMTEXT       Total Hours Est. Next 12 Months:  FORMTEXT      Total Hours As PIC in AX10C (7 Passengers)  FORMTEXT      Total Hours Last 12 Months:  FORMTEXT       Total Hours Est. Next 12 Months:  FORMTEXT      Total Hours As PIC in AX10B (8 Passengers)  FORMTEXT      Total Hours Las.^`   . 0 2 < > N P d f h r t û÷÷ûû}÷rjhVmUjhVmUjzhVmUjh)#UmHnHujthVmUjhVmUh)#jh)#U h6h@hah@5CJ aJ hah@CJaJhh@5CJ aJ hqe5CJ aJ h@5CJ aJ ,`@ v czkd$$Ifl0*p t0644 la $$Ifa$gd@$a$gd@$a$gdqegd@ JJv x ww $$Ifa$gd@|kdb$$Ifl40*p` t0644 la  b ww $$Ifa$gd@|kdp$$Ifl40*p  t0644 la    8 : < P R T ^ ` | ~ & ( * > @ B L N  j|hVmUjthVmUjhVmUjhVmUjhVmUj~hVmUjh)#UmHnHuj hVmUjh)#Uh)#h@ h6h@8b d xx $$Ifa$gd@zkd$$Ifl0*p t0644 la P xx $$Ifa$gd@zkdl$$Ifl0*p t0644 la  n xx $$Ifa$gd@zkd$$Ifl0*p t0644 la  B F H \ ^ ` j l p  & ( * , 6 8  "$&02\^jlnϵjN hVmUj hVmUj hVmUhVmjn hVmUj hVmUh@jh)#UmHnHujhVmUh)# h6h@jh)#U:n p 8 xx $$Ifa$gd@zkdh $$Ifl0*p t0644 la 4 $$Ifa$gd@ $Ifgd@ikdX $$Ifl*+ t0644 la046LPRfhjtv024>@v|~ ^bjhVmUjhVmUjhVmUj4hVmUj hVmUh@ h6h@jh)#UmHnHuj hVmUh)#jh)#U<xB{oo $$Ifa$gd@ $Ifgd@zkd: $$Ifl0* t0644 laBD {oo $$Ifa$gd@ $Ifgd@zkd $$Ifl0* t0644 labdxz|02@BVXZdfhr  "$&(<>@JLvxjhVmUjphVmUjvhVmUjhVmUjhVmUh@ h6h@jh)#UmHnHujhVmUh)#jh)#U<h{oo $$Ifa$gd@ $Ifgd@zkd$$Ifl0* t0644 laN{oo $$Ifa$gd@ $Ifgd@zkd$$Ifl0* t0644 la PTVlnpr6:<PRT^`@ @ @@@@0@2@4@>@ӡjhVmUUj<hVmUjBhVmUjhVmUjVhVmUh@ h6h@jh)#UmHnHuj\hVmUh)#jh)#U;b{oo $$Ifa$gd@ $Ifgd@zkd$$Ifl0* t0644 labdB@@{oo $$Ifa$gd@ $Ifgd@zkd$$Ifl0* t0644 lat 12 Months:  FORMTEXT       Total Hours Est. Next 12 Months:  FORMTEXT      Total Hours As PIC in AX10 (10 Passengers)  FORMTEXT      Total Hours Last 12 Months:  FORMTEXT       Total Hours Est. Next 12 Months:  FORMTEXT       DISCLOSURE INFORMATION: EXPLAIN YES ANSWERS BELOW Have you ever been involved in any aircraft incident or accident, including Property Damage? FORMCHECKBOX  Yes  FORMCHECKBOX  NoHave you ever been cited by a regulatory authority? FORMCHECKBOX  Yes  FORMCHECKBOX  NoHas your license ever been suspended or revoked? FORMCHECKBOX  Yes  FORMCHECKBOX  NoHave you ever been charged with DUI or DWI? FORMCHECKBOX  Yes  FORMCHECKBOX  NoHave you ever had an application for aviation insurance denied? FORMCHECKBOX  Yes  FORMCHECKBOX  NoExplain  YES answers here:  FORMTEXT       By signing below, I hereby represent that all information is true and I have completed this from personally. I also agree to allow the company to investigate my FAA records, Motor Vehicle Records and credit or other background reports. Signature or Typed Full Name:  FORMTEXT       Date:  FORMTEXT       COVERAGE APPLIES ONLY TO PILOTS NAMED ON THE POLICY. ALL PILOTS PROPOSED FOR COVERAGE MUST HAVE A FULLY COMPLETED AND SIGNED PILOT INFORMATION QUESTIONNAIRE.     >@@@B@@@@@@@@@@@@AAAAAA(A*ATAVA`AdAfAzA|A~AAAAAAAAAAAAA^B`BBBB CCC8C:CCDCHCJCfC쩡jhVmUh6h@5 hVm5jhVmUjhVmUj"hVmUjh)#UmHnHuj(hVmUh)# h6h@h@jh)#U9@@,AAA{oo $$Ifa$gd@ $Ifgd@zkd$$Ifl0* t0644 laAAA`BCrC|thh $$Ifa$gd@$a$gd@$a$gd@zkd$$Ifl0* t0644 lafChCjClCCCCCCDD D D(D*D,D.D2DDDDDDDDDDDDDDDDDJELEhEjElEnEtExEzEEEEEE$F&FBFDFFFHFNFj h)#Ujh)#UjLh)#UjTh)#Ujh)#Uh@jh)#U h6h)#jth)#U h6h@h)#jh)#Uj|hVmU6rCtCC4Dxx $$Ifa$gd@zkd$$Ifl0* t0644 la4D6DDDxx $$Ifa$gd@zkd\$$Ifl0* t0644 laDDJEExx $$Ifa$gd@zkd$$Ifl0* t0644 laEE$F|Fxx $$Ifa$gd@zkd4 $$Ifl0* t0644 laNFRFTFpFrFtFvFzFFFFFFFFFFHNHHHHHHIIII I.I0I8IIRITIVI`IbIdIfIIJJJtJvJJJJJJ۾jhw Uhdox h/h@ h@5hOh@5 h)#5j#hVmUj#hVmUh@jh)#UmHnHuj$"hVmU h6h@ h6h)#j,!h)#Ujh)#Uh)#3|F~FFFxx $$Ifa$gd@zkd!$$Ifl0* t0644 laFFHHdIfIJJJJJJJJJJJ$a$gd@ikd"$$Ifl*+ t0644 laJJJJJJJJJhdoxjhw Uhw JJ&1h:p@/ =!"#$%tDText1tDText2$$If!vh5p5#vp#v:V l t065p5tDText3tDText4$$If!vh5p5#vp#v:V l4 t06+5p5tDText5$$If!vh5p5#vp#v:V l4 t06+5p5tDText6tDText7$$If!vh5p5#vp#v:V l t065p5tDText8tDText9$$If!vh5p5#vp#v:V l t065p5vDText10vDText11$$If!vh5p5#vp#v:V l t065p5vDText12vDText13$$If!vh5p5#vp#v:V l t065p5tDeCheck1tDeCheck2vDText14~$$If!vh5+#v+:V l t065+vDText15vDText16vDText17$$If!vh55#v:V l t065vDText18vDText19vDText20$$If!vh55#v:V l t065vDText21vDText22vDText23$$If!vh55#v:V l t065vDText24vDText25vDText26$$If!vh55#v:V l t065vDText27vDText28vDText29$$If!vh55#v:V l t065vDText30vDText33vDText34$$If!vh55#v:V l t065vDText31vDText35vDText36$$If!vh55#v:V l t065vDText32vDText37vDText38$$If!vh55#v:V l t065tDeCheck3tDeCheck4$$If!vh55#v:V l t065tDeCheck3tDeCheck4$$If!vh55#v:V l t065tDeCheck3tDeCheck4$$If!vh55#v:V l t065tDeCheck3tDeCheck4$$If!vh55#v:V l t065tDeCheck3tDeCheck4$$If!vh55#v:V l t065vDText39~$$If!vh5+#v+:V l t065+vDText40vDText41@@@ @NormalCJ_HaJmH sH tH DA@D Default Paragraph FontRi@R  Table Normal4 l4a (k@(No List 4 @4 @Footer  !:O: @ CharCJ_HaJmH sH tH 4@4 qeHeader  !a f0Ba|}12S|}78J~!"`4ij  L|!VW0  L x y  > ? o p q ^ _ R S T U X [ ^ b 00000 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 00 0 0 00 0 0 00 0 0 00 0 0 00 0 0 00 0 0 00 0 0 00 0 0 00 0 0X0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 00 0 0`0000@00 9@00@00@00@000;    b>@fCNFJJ &).1v b n Bb@ArC4DDE|FFJJ '(*+,-/02J MY_htz )/?KQhtz#/5n~6BHjv| LX^| ,2Uag 8DJhtz BNT  L \ c s  " ) 9 [ g m } a FFFFFFFFFFFFFG G FFFFFFFFFFFFFFFFFFFFFFFFFG G G$G$G$G$G$G$G$G$FFF8@0(  B S  ?-Text1Text2Text3Text4Text5Text6Text7Text8Text9Text10Text11Text12Text13Check1Check2Text14Text15Text16Text17Text18Text19Text20Text21Text22Text23Text24Text25Text26Text27Text28Text29Text30Text33Text34Text31Text35Text36Text32Text37Text38Check3Check4Text39Text40Text41Ni@i$o7kM}!V9iC\ ~ b   !"#$%&'()*+,`{ 0R{6I} _3h K{ Un b S S U U V V X Y [ \ ^ _ b S S U U V V X Y [ \ ^ _ b 3Z_h{ 0?Rh{#6n6Ij}  L_| 3Uh 8Kh{  BU//[ n } R b S S U U V V X Y [ \ ^ _ b ! .-)#ZpHRw $H1F?$uKK6PF8V6_Vmdox<8y {4uBrM@JKLqe S1H /}Y!M0Ba|}12S|}78~!"`ij  LVW0  L x y  > ? p q R b i0i0@wLa `` ````@UnknownGz Times New Roman5Symbol3& z Arial"1h44} } !4M M 2QHP ? /THE SCHANTZ AGENCY & T John Griffin #O From: "John Griffin" To: "john Griffin work" Subject: Pilot Info Form 8-29-09 Date: Sun, 6 Sep 2009 18:14:29 -0400 MIME-Version: 1.0 Content-Type: text/plain; charset="iso-8859-1" Content-Transfer-Encoding: 7bit X-Priority: 3 X-MSMail-Priority: Normal X-MimeOLE: Produced By Microsoft MimeOLE V6.00.2900.5579 Oh+'0x  4 @ LX`hpTHE SCHANTZ AGENCY & TJohn GriffinPilot Info Form 9-6-09 3Microsoft Word 10.0@@2^>/@U?/} ՜.+,0 hp|  M  THE SCHANTZ AGENCY & T Title  !"#$%&'()*+,-./012356789:;<=>?@ABCDEFHIJKLMNOPQRSTUVWXZ[\]^_`bcdefghkRoot Entry Fܞg?/mData 4$1TableGt#WordDocument(fSummaryInformation(YDocumentSummaryInformation8aCompObjj  FMicrosoft Word Document MSWordDocWord.Document.89q