JANET NAPOLITANO WILLIAM BELL

GOVERNOR DIRECTOR

ARIZONA DEPARTMENT OF ADMINISTRATION

RISK MANAGEMENT SECTION
th
100 North 15 AVENUE, SUITE #301
Phoenix, Arizona 85007-2635
Telephone: (602) 542 1445; Facsimile: (602) 542 1800

PILOT APPLICATION (COMPLETE ENTIRE FORM)

PILOT HISTORY
PILOT NAME: DAYTIME PHONE: #
ADDRESS:
DATE OF BIRTH: DRIVER’S LICENSE #/STATE:
AIRMAN’S CERT.: # MED. CLASS & EXP. DATE:
ARE YOU A STATE EMPLOYEE? AGENCY:
HOW OFTEN DO YOU FLY ON STATE PURPOSE OF FLYING ON STATE BUSINESS?
BUSINESS? ANNUAL FLIGHTS:
ANNUAL HOURS:
OCCUPATION:

If the answer to any of the following questions is yes, please give detail on YES NO
separate sheet.
Have you ever had any aircraft accidents?
Have you ever been cited for violations of civil/military aviation regulations?
Are you flying subject to limitations or a waiver?
Has your driver’s license ever been suspended or revoked?
Have you been arrested for operating a vehicle while under the influence of alcohol or
drugs?
Have you had any automobile accidents within the last five years?

CERTIFICATES / RATINGS
Indicate all certificates you currently hold:
‰ Student ‰ Airline (ATR) ‰ Single Engine Land
‰ Private ‰ Instructor ‰ Multi Engine Land
‰ Commercial ‰ Instrument Rating ‰ Helicopter
List all aircraft type ratings you currently hold:

List all Manufacturer’s Ground and Flight Schools and dates you have attended for each aircraft make
and model:

Indicate date of your last biennial flight review and list if it was VFR or IFR:
 FLYING EXPERIENCE IN LOGGED HOURS
PILOT-IN-COMMAND ONLY
SPECIIFY ALL MAKE AND MODELS LAST 12 LAST 90 TOTAL LOGGED
MONTHS DAYS HOURS
ALL SINGLE
ENGINE
FIXED WING/GEAR
OR
RETRACTABLE
GEAR
MULTI ENGINE
PISTON
MULTI ENGINE
TURBINE
HELICOPTER PISTON:

HELICOPTER TURBINE:

AIRCRAFT INFORMATION
TYPES OF AIRCRAFT YOU OPERATE YEAR MAKE MODEL FAA#
STATE OWNED AIRCRAFT:

OWNED, BORROWED OR RENTED AIRCRAFT:

Borrowed or owned private aircraft (attach certificate of
insurance providing evidence of $1,000,000 minimum
Aircraft liability including passengers)
I CERTIFY THAT THE STATEMENTS I HAVE MADE IN THE PILOT APPLICATION TO BE THE
BEST OF MY KNOWLEDGE AND BELIEF.

PILOT SIGNATURE:_________________________________________ DATE:________________

APPROVED BY: ___________________ FOR SEFG SERG MEU HELI DATE:_______________

PILOT APP (5-04) KLR
 MINIMUM PILOT QUALIFICATIONS
QUESTIONS: CALL KRIS ROWEN: (602) 542-1445

1. SINGLE ENGINE AIRCRAFT - FIXED GEAR:

Holds a currently effective certificate issued by the Federal Aviation Administration designating him or her
a private or commercial pilot with airplane category and single engine land rating with IFR and has a
minimum of 250 total logged flying hours.

2. SINGLE ENGINE AIRCRAFT - RETRACTABLE GEAR:

Holds a currently effective certificate issued by the Federal Aviation Administration designating him or her
a private or commercial pilot with airplane category and single engine land rating with IFR and who has a
minimum of 500 total logged flying hours including at least 100 hours in aircraft having retractable landing
gear.

3. PISTON-POWERED MULTI-ENGINE AIRCRAFT HAVING A MAXIMUM CERTIFICATED

GROSS WEIGHT OF LESS THAN 7,500 POUNDS:

Holds a currently effective certificate issued by the Federal Aviation Administration designating him or her
a Commercial pilot airplane category including multi-engine land and instrument ratings and who has a
minimum of 1,500 total logged flying hours including at least 250 hours in multi-engine aircraft of which
not less than 25 hours have been in the make and model aircraft to be flown.

4. PISTON-POWERED MULTI-ENGINE AIRCRAFT HAVING A GROSS WEIGHT OF MORE THAN

7,500 POUNDS BUT LESS THAN 12,500 POUNDS:

Holds a currently effective certificate issued by the Federal Aviation Administration designating him or her
a commercial pilot with airplane category including multi-engine land and instrument ratings and who has
a minimum of 2,500 total logged flying hours including at least 750 hours in multi-engine aircraft of which
not less than 50 hours have been in the make and model to be flown.

5. TURBO-PROP AIRCRAFT - THE FOLLOWING SHALL APPLY:

Any person while holding a currently effective certificate issued by the Federal Aviation Administration
designating him or her a Commercial pilot airplane category including multi-engine land and instrument
ratings and who has a minimum of 3,000 total logged flying hours as pilot in command including at least
1,000 hours in multi-engine aircraft of which not less than 25 hours have been in Beech King Air 90
Model Aircraft and provided he or she has successfully completed the manufacturer’s recommended
ground and flight school or its equivalent for Beech King Air 90 Model Aircraft.

6. ROTARY WING AIRCRAFT:

Holds a currently effective certificate issued by the Federal Aviation Administration designating him or her
a commercial pilot with rotor wing rating and who has logged at least 1,500 total flying hours of which
1,000 hours shall be in turbine powered rotary wing aircraft including no less than 250 hours in the made
and model being flown and provided he or she has successfully completed the manufacturer’s
recommended ground and flight school or its equivalent.

PILOTQUAL/4-03KLR
AZ Secretary of State - Jan Brewer Arizona Administrative Code
--------------------------------------------------------------------------------
AAC Table of Contents

TITLE 2. ADMINISTRATION
CHAPTER 10. DEPARTMENT OF ADMINISTRATION
RISK MANAGEMENT SECTION

Supp. 02-2

(Authority: A.R.S. § 41-621 et seq.)

Laws 1983, Ch. 98, 121, transferred authority for Risk Management Services to the Director of
Administration effective July 27, 1983.
Article 1 consisting of Sections R2-10-101 through R2-10-105; Article 2 consisting of Sections R2-10-201
through R2-10-204; Article 3 consisting of Sections R2-10-301 through R2-10-304 adopted effective July
27, 1983.

Former Sections R2-10-01 through R2-10-05, R2-10-50 through R2-10-53, R2-10-100 through R2-10-
103 renumbered and readopted with conforming changes.

ARTICLE 1. COVERAGE AND CLAIMS PROCEDURE

Section

R2-10-101. Definitions
R2-10-102. Reporting Procedures
R2-10-103. Liability Claim Procedures
R2-10-104. Self-insured Property Claim Procedures
R2-10-105. Employment Discrimination Claim Procedures
R2-10-106. State-owned Property Coverage and Limitations
R2-10-107. Liability Coverage and Limitations
R2-10-108. Deductibles and Waivers
R2-10-109. Computation of Time

R2-10-107. Liability Coverage and Limitations

A. The following coverage and limitations apply in this Chapter:

1. The Department provides liability coverage within the limitations of A.R.S. § 41-621 for an
officer, agent, or employee while driving a state-owned or other vehicle in the course and scope of
employment.

a. Each agency shall ensure that an individual operating a vehicle on state business has
a valid driver's license.

b. Coverage shall be on a primary basis for a state-owned, leased, or rented vehicle and
on an excess basis for any other vehicle.

c. The state shall not provide coverage for damage or loss of a personal vehicle.

2. An officer, agent, or employee operates a state-owned vehicle within the course and scope of
employment if driving:

a. On authorized state business,

 b. To and from work,

c. To and from lunch on a working day,

d. To and from meals while on out-of-town travel.

3. An officer, agent, or employee does not operate a personal vehicle within the course and
scope of employment when driving:

a. To and from work,

b. To and from lunch in the area of employment and not on authorized state business,

c. On other than state-authorized business.

B. A volunteer acting at the direction of a state official, within the course and scope of state-authorized
activities, is covered under A.R.S. § 41-621.

C. A claim alleging a civil rights violation is covered through RM, except there is no coverage for payment
of that portion of a settlement or judgment for position status adjustments.

D. The state shall cover an agent, officer, or employee for liability on an excess basis while using the
agent, officer, or employee's personal aircraft within the course and scope of employment with the state
under the following guidelines:

1. An agent, officer, or employee shall carry a minimum of $1,000,000 in aircraft liability

coverage.

2. RM shall approve an agent, officer, or employee pilot prior to flying on state business. To
obtain this approval, an agent, officer, or employee shall complete an RM pilot application form that
requests the pilot's name, airman's certificate number, driver's license number, aircraft description, rating,
and flying hours, and submit it to RM for review with a certificate of insurance evidencing the required
limits of coverage on a personal aircraft. To maintain RM approval, an agent, officer, or employee pilot
shall submit an updated pilot application form and certificate of insurance annually.

3. RM shall send a letter to an agent, officer, or employee approving or rejecting an application to

fly a personal aircraft on state business. The approval letter shall be presented to the appropriate
department head and a copy sent to the agency's loss prevention coordinator.

4. An agent, officer, or employee shall maintain a current FAA pilot certification.

5. An agent, officer, or employee shall meet the pilot warranties in the aircraft insurance policy
owned by the state.

6. An agent, officer, or employee shall hold all licenses, certificates, endorsements, and other
qualifications, including proficiency checks and recent experience, required by the FAA or other federal,
state, or local statutes and rules to act as pilot-in-command or as a required crew member for the aircraft
being flown. The pilot-in-command shall meet current requirements for carrying passengers.

7. Course and scope of employment with the state does not include:

a. Personal use of an aircraft;

b. An aircraft for hire, reward or commercial use;

 c. Agricultural operations;

d. Carrying external loads;

e. Performing aerial acrobatics.

8. An agent, officer, or employee shall carry no more passengers on an aircraft than the number
defined in the aircraft insurance policy purchased by RM.

9. The Department shall not cover damage or loss of the agent, officer, or employee-owned
aircraft.

10. The guidelines in this Section apply to a non-state employee pilot flying on behalf of an agent,
officer, or employee on authorized state business.

11. All aircraft used for state business shall comply with all statutes and rules of the FAA and
other federal, state, and local jurisdictions for flight.

Historical Note

Renumbered from R2-10-105(C) through (J) and amended effective December 18, 1992 (Supp. 92-4).
Amended effective January 12, 1995 (Supp. 95-1).

Section corrected to reflect amendment on file with the Office of the Secretary of State effective January
12, 1995 (Supp. 97-1). Amended by final rulemaking at 6 A.A.R. 1717, effective April 20, 2000 (Supp. 00-
2).