+-----------+-----------------------------------------------------------+
| ![](m     | **AGENCY DISPLAY OF ESTIMATED BURDEN**                    |
| edia/imag |                                                           |
| e1.wmf){w | The public reporting burden for this collection of        |
| idth="0.8 | information is estimated to average 30 minutes per        |
| 694444444 | response. If you wish to comment on the accuracy of the   |
| 444445in" | estimate or make suggestions for reducing this burden,    |
| hei       | please direct your comments to: U.S. Department of        |
| ght="0.87 | Transportation, Office of Aviation Analysis, X-56, 400    |
| 916666666 | 7^th^ St., SW,., Washington, D.C. 20590. According to the |
| 66667in"} | Paperwork Reduction Act of 1995, no persons are required  |
|           | to respond to a collection of information unless it       |
| Office of | displays a valid OMB control number.                      |
| the       |                                                           |
| Secretary | **NOTE**: For information on where to file completed      |
|           | copies of this form, see [**FILING                        |
| of        | INSTRUCTIONS**]{.underline} below.                        |
| Trans     |                                                           |
| portation |                                                           |
+-----------+-----------------------------------------------------------+

OMB No. 2106-0030 Expires 9-30-2007  

+-----------------------------------------------------------------------+
| **FOREIGN AIR CARRIERS - CERTIFICATE OF INSURANCE**                   |
|                                                                       |
| ## POLICIES OF INSURANCE FOR AIRCRAFT ACCIDENT BODILY INJURY          |
|                                                                       |
| # AND PROPERTY DAMAGE LIABILITY                                       |
|                                                                       |
| **[FILING INSTRUCTIONS]{.underline}:** File a signed original of this |
| form with the Federal Aviation Administration, Air Transportation     |
| Div., AFS-260, 800 Independence Ave., SW., Washington, DC 20591. (See |
| **EXCEPTION** below.)                                                 |
|                                                                       |
| **[EXCEPTION]{.underline}**: If Section 2.A. is filled in because the |
| insured is a *Canadian Charter Air Taxi Operator*, file an original   |
| of this form with the U.S. Department                                 |
|                                                                       |
| of Transportation, Special Authorities Division (X-46), 400 7^th^     |
| Street, SW, Washington, D.C. 20590                                    |
|                                                                       |
| *(Please type information, except signatures.)*                       |
|                                                                       |
| **THIS CERTIFIES THAT:**                                              |
| \_\_\_\_\_\_\_\_\_\_\_\_                                              |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                                                                       |
| (Name of Insurer)                                                     |
|                                                                       |
| has issued a policy or policies of Aircraft Liability Insurance to    |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\                                   |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                                                                       |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_    |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_FAA |
| Certificate Number\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                    |
|                                                                       |
| (Name, address and FAA Certificate number of Insured Foreign Air      |
| Carrier)                                                              |
|                                                                       |
| effective from \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_   |
| until ten (10) days after written notice from the insurer or carrier  |
| of the intent                                                         |
|                                                                       |
| to terminate coverage is received by the Department of                |
| Transportation.                                                       |
|                                                                       |
| NOTE: Part 205 of the Department's Regulations does not allow for a   |
| predetermined termination date, and a certificate showing such a date |
| is unacceptable.                                                      |
|                                                                       |
| \_\_\_\_\_\_\_\_\                                                     |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_1. |
| The Insurer *([Check One]{.underline})*:                              |
|                                                                       |
| is licensed to issue aircraft insurance policies in the United        |
| States;                                                               |
|                                                                       |
| is licensed or approved by the government of                          |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ to issue aircraft      |
| insurance policies; or                                                |
|                                                                       |
| is an approved surplus line insurer in the State(s) of                |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                    |
|                                                                       |
| \_\_\_\_\_\_\_\_\                                                     |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_2. |
| The insurer assumes, under the policy or policies listed below,       |
| aircraft accident liability insured to minimums at least equal to the |
| following during operation, maintenance, or use of aircraft in        |
| "foreign air transportation" as that term is defined in 49 U.S.C.     |
| 40102.                                                                |
|                                                                       |
| *([Complete applicable section A, B, or C below]{.underline}):*       |
|                                                                       |
| > **A. CANADIAN CHARTER AIR TAXI OPERATORS WITH PART 294 AUTHORITY    |
| > ONLY**                                                              |
| >                                                                     |
| > The aircraft covered by this policy have: (1) 30 or fewer passenger |
| > seats and a maximum payload capacity of 7,500 pounds or less;       |
| > and/or (2) a maximum authorized takeoff weight on wheels of no more |
| > than 35,000 pounds. *([Complete separate or combined coverage as    |
| > appropriate]{.underline})*:                                         |
| >                                                                     |
| > Separate Coverages: *[Minimum Limit                  ]{.underline}* |
| >                                                                     |
| > *[Policy No. Type of Liability Each person Each                     |
| > Occurrence    ]{.underline}*                                        |
| >                                                                     |
| > \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Combined Bodily Injury         |
| > (Excluding Passengers other                                         |
| >                                                                     |
| > than cargo attendants) and Property Damage Liability \$75,000       |
| > \$2,000,000\*(See note)                                             |
| >                                                                     |
| > \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Passenger Bodily Injury        |
| > \$75,000 \$75,000 x 75% of                                          |
| >                                                                     |
| > total number of                                                     |
| >                                                                     |
| > passenger seats                                                     |
| >                                                                     |
| > installed in aircraft                                               |
| >                                                                     |
| > Combined Coverage: This combined coverage is a single limit of      |
| > liability for each occurrence at least equal to the required        |
| > minimums stated above for bodily injury (excluding passengers),     |
| > property damage, and passenger bodily injury.                       |
| >                                                                     |
| > *Policy                                                             |
| > No.                                                                 |
| *\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| > Amount of Coverage\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_U.S.    |
| > Dollars                                                             |
| >                                                                     |
| > This policy covers CARGO operations *only* and *excludes* passenger |
| > liability insurance.                                                |
| >                                                                     |
| > \_\_\_\                                                             |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| >                                                                     |
| > **NOTE**: If the aircraft covered by this policy have more than 30  |
| > passenger seats or more than a maximum payload capacity of 7,500    |
| > pounds, the minimum limit per occurrence shall be \$20,000,000.     |
+-----------------------------------------------------------------------+

**OST Form 6411**

+-----------------------------------------------------------------------+
| > **B. FOREIGN AIR CARRIERS OPERATING SMALL AIRCRAFT**                |
| >                                                                     |
| > The aircraft covered by this policy are SMALL AIRCRAFT (i.e., with  |
| > 60 or fewer passenger seats or with a maximum payload               |
| >                                                                     |
| > capacity of 18,000 pounds or less). *([Complete separate or         |
| > combined coverage as appropriate]{.underline})*:                    |
| >                                                                     |
| > Separate Coverages: *[Minimum                                       |
| > Limit                   ]{.underline}*                              |
| >                                                                     |
| > *[Policy No. Type of Liability Each person Each                     |
| > Occurrence    ]{.underline}*                                        |
| >                                                                     |
| > \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Combined Bodily Injury         |
| > (Excluding Passengers other                                         |
| >                                                                     |
| > than cargo attendants) and Property Damage Liability \$300,000      |
| > \$2,000,000                                                         |
| >                                                                     |
| > \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Passenger Bodily Injury        |
| > \$300,000 \$300,000 x 75% of                                        |
| >                                                                     |
| > total number of                                                     |
| >                                                                     |
| > passenger seats                                                     |
| >                                                                     |
| > installed in aircraft                                               |
| >                                                                     |
| > Combined Coverage: This combined coverage is a single limit of      |
| > liability for each occurrence at least equal to the required        |
| > minimums stated above for bodily injury (excluding passengers),     |
| > property damaged, and passenger bodily injury.                      |
| >                                                                     |
| > *Policy                                                             |
| > No.                                                                 |
| *\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| > Amount of Coverage\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_U.S.    |
| > Dollars                                                             |
| >                                                                     |
| > This policy covers CARGO operations *only* and *excludes* passenger |
| > liability insurance.                                                |
|                                                                       |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\                     |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**C. |
| FOREIGN AIR CARRIERS OPERATING LARGE AIRCRAFT**                       |
|                                                                       |
| > The aircraft covered by this policy are LARGE AIRCRAFT (i.e., with  |
| > more than 60 passenger seats or with a maximum payload capacity of  |
| > more than 18,000 pounds). *([Complete separate or combined coverage |
| > as appropriate]{.underline})*:                                      |
| >                                                                     |
| > Separate Coverages: *[Minimum                                       |
| > Limit                     ]{.underline}*                            |
| >                                                                     |
| > *[Policy No. Type of Liability Each person Each                     |
| > Occurrence    ]{.underline}*                                        |
| >                                                                     |
| > \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Combined Bodily Injury         |
| > (Excluding Passengers other                                         |
| >                                                                     |
| > than cargo attendants) and Property Damage Liability \$300,000      |
| > \$20,000,000                                                        |
| >                                                                     |
| > \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Passenger Bodily Injury        |
| > \$300,000 \$300,000 x 75% of                                        |
| >                                                                     |
| > total number of                                                     |
| >                                                                     |
| > passenger seats                                                     |
| >                                                                     |
| > installed in aircraft                                               |
| >                                                                     |
| > Combined Coverage: This combined coverage is a single limit of      |
| > liability for each occurrence at least equal to the required        |
| > minimums stated above for bodily injury (excluding passengers),     |
| > property damaged, and passenger bodily injury.                      |
| >                                                                     |
| > *Policy                                                             |
| > No.                                                                 |
| *\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| > Amount of Coverage\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_U.S.    |
| > Dollars                                                             |
| >                                                                     |
| > This policy covers CARGO operations *only* and *excludes* passenger |
| > liability insurance.                                                |
|                                                                       |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\                         |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                                                                       |
| 3\. The policy or policies listed in this certificate insure(s)       |
| *([Check One]{.underline})*: Make and Model FAA or Foreign Flag       |
|                                                                       |
| [Registration No.      ]{.underline}                                  |
|                                                                       |
| > Operations conducted with all aircraft operated by the insured      |
| >                                                                     |
| > Operations conducted with the following types of aircraft:          |
| >                                                                     |
| > Operations with the following aircraft: (Use additional page if     |
| > necessary)                                                          |
|                                                                       |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\                         |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                                                                       |
| 4\. Each policy listed in this certificate meets or exceeds the       |
| requirements in 14 CFR Part 205.                                      |
|                                                                       |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\             |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\                     |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                                                                       |
| *(Name of Insurer) (Name of Broker, if applicable)*                   |
|                                                                       |
| *\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\            |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                    |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_* |
|                                                                       |
| *(Address) (Address)*                                                 |
|                                                                       |
| *\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\            |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\                     |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| (City, State, Zip Code) (City, State, Zip Code)*                      |
|                                                                       |
| *\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\            |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                    |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_* |
|                                                                       |
| *Contact (person who can verify the effectiveness of the coverage)    |
| (Officer or authorized representative)*                               |
|                                                                       |
| *\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_           |
| \_\_\_/\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\                     |
| _\_\_\_\_\_\_\_/\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_* |
|                                                                       |
| *(Area Code, Phone Number) (Area Code, Fax Number) (Area Code, Phone  |
| Number) (Area Code, Fax Number)*                                      |
|                                                                       |
| *\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\          |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                      |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_* |
|                                                                       |
| *(Signature, if applicable) (Signature)*                              |
|                                                                       |
| *\_\_\_\_\_\_\_\_\_\                                                  |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| \_\_\_\_\_\_\_\_\_                                                    |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_* |
|                                                                       |
| *(Date) (Date)*                                                       |
+-----------------------------------------------------------------------+