To be considered as a named pilot
WENK AVIATION INSURANCE, LLC
900 North Shore Drive, Suite 109 Lake Bluff, IL 60044 OP ID: TWD
PH: (847) 235-2491 FAX: (847) 235-2559 FAA PILOT CERTIFICATES
Name: Student CFI
Private CFII
Street Address:
Commercial MEI
City/State/Zip: ATP CFI-Rotor
Other:
Phone: E-Mail Address:
Birth date: Certificate Number: FAA PILOT RATINGS
Occupation: ASEL ASES
AMEL AMES
Employer:
Instrument Rotor
Glider
FAA MEDICAL CERTIFICATE Other:
Date issued: Class:
Waivers, Conditions or Limitations (If none, write none):
INITIAL AND RECURRENT TRAINING
Date of last Flight Review:
Date of last Instrument Proficiency Check:
Date of last ground & flight training in Cessna 414A: Name of School:
LOGGED HOURS
AIRCRAFT TYPE TOTAL HOURS HOURS LAST 12 MONTHS
All aircraft:
Retractable gear:
Multi-engine:
Cessna 414A:
IN THE LAST FIVE YEARS,
1. Have you been involved in any aircraft incidents, accidents or claims?
No Yes (PLEASE ADVISE DATE and EXPLANATION):
2. Have you been penalized, disciplined, or fined for a violation of any FARs?
No Yes (PLEASE ADVISE DATE and EXPLANATION):
3. Has your pilot's license or driver's license been suspended or revoked?
No Yes (PLEASE ADVISE DATE and EXPLANATION):
4. Have you been convicted of or pleaded guilty to A) a charge of driving under the influence of alcohol or drugs, or B) a felony?
No Yes (PLEASE ADVISE DATE and EXPLANATION):
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.
FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing 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. In some
jurisdictions, insurance fraud may also be subject to substantial civil penalties.
Signed: Date:_________________________________________
(Pilot’s Personal Signature Required)
This pilot record is filed in connection with the Insurance Application of: Pura Plastic Surgery, LLC,
