Office of the Secretary

of Transportation AGENCY DISPLAY OF ESTIMATED BURDEN

The public reporting burden for this collection of information is estimated to average 30 minutes per response. If you wish

to comment on the accuracy of the estimate or make s uggestions for reducing this burden, please direct your comments

to: U.S. Department of Transportation, Office of Aviation Analysis, X

- 56, 400 7 th St., SW., Washington, D.C. 20590.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information

unless it displays a valid OMB control number.

NOTE : For information on where to file completed copies of this form, see FILING INSTRUCTIONS below.

OMB No. 2106

- 0030 Expires 9

- 30

- 2007

U.S. AIR CARRIERS

- C ERTIFICATE OF INSURANCE

POLICIES OF INSURANCE FOR AIRCRAFT ACCIDENT BODILY INJURY

AND PROPERTY DAMAGE LIABILITY

FILING INSTRUCTIONS : File a signed original of this form with the Federal Aviation Administration, AFS

- 260, 800 Independence Ave., S.W.,

Washi ngton, D.C. 20591. (See EXCEPTIONS 1 and 2 below.)

EXCEPTION 1 : If Block 2B on the reverse is filled in because the insured is a commuter air carrier , file a signed original of this form with the

Department of Transportation, Air Carrier Fitness Divis ion, X

- 56, 400 7 th St., SW, Washington, DC 20590.

EXCEPTION 2 : For any insured that is located in the State of Alaska (regardless as to whether Block 2A, 2B, or 2C is filled in), file a signed

original of this form with the Federal Aviation Administrat ion, Alaskan Region Hq., AAL

- 230, 222 W. 7 th Ave., #14, Anchorage, Alaska 99513.

(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 of Insured U.S. Air Car rier) ____ _________ __

effective from

___ ____________ __

NOTE: Part 205 of the Department’s Regulations does not allo w for a predetermined termination date, and a certificate showing such a date is

unacceptable. 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.

1. The Insurer ( Check One

; is licensed to issue aircraft insurance policies in the United States; ) :

is licensed or approved by the government of

_______________________ is an approved surplus line insurer in the State(s) of to issue aircraft insurance policies; or

2. The insurer assumes, under the policy or policies listed below, aircraft accident liability in sured to minimums at least equal to _________________________

the following during operation, maintenance, or use of aircraft in “air transportation” as that term is defined in 49 U.S.C. 40102.

( Complete applicable section(s) A, B, or C below

A. U.S. AIR TAXI OPERATORS ( ):

EXCLUDING

The aircraft covered by this policy are SMALL AIRCRAFT (i.e., with 60 or fewer passenger seats or with a maximum payload capa city of

18,000 pounds or less). ( U.S. COMMUTER AIR CARRIERS) WITH PART 298 AUTHORITY ONLY:

Complete separate or combine d coverage as appropriate

Separate Coverages: ) :

Minimum Limit

Policy Number Type of Liability Each Person Each Occurrence

Bodily Injury Liability

(Excluding Passengers) $75,000 $300,000

Passenger Bodily Injury $75,000 $75,000 x 75 % of total number

of passenger seats installed in

aircraft

Property Damage $100,000

Combined Coverage: The amount of coverage set forth below is a single limit of liability for each occurrence at least equal to the

required minimums stated above f or bodily injury (excluding passengers), property damage, and passenger bodily injury.

Policy Number Amount of Coverage

This policy covers CARGO operations only and excludes passenger liability insurance.

OST Form 6410 XL Specialty Insurance Company

Boutique Air , Inc.

– 340 Pine Street, Suite 503 San Francisco, CA 94104 

### 2B5A106N

N ovember 15 , 2012B. U.S. COMMUTER AIR CARRIER S OR

The aircraft covered by this policy are SMALL AIRCRAFT (i.e., with 60 or fewer passenger seats or with a maximum payload CERTIFICATED AIR CARRIERS OPERATING SMALL AIRCRAFT

capacity of 18,000 pounds or less). ( Complete separate or combined coverage a s appropriate

; Separate Coverages: ) :

Minimum Limit

Policy Number Type of Liability Each Person Each Occurrence

UA00007 828 AV12A Combined Bodily Injury (Excluding Passengers other than cargo

attendants) and Property Damage Liability $300,000 $2,000,000

UA00007 828 AV12A Passenger Bodily Injury $300 ,000 $300 ,000 x 75% of total

number of passenger

seats installed in aircraft

Combined Coverage: The amount of coverage set forth below 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 Number Amount of Coverage

This policy covers CARGO operations only and excludes passenger liability insurance.

C. U.S . CERTIFICATED 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 cap acity of

more than 18,000 pounds). ( Complete separate or combined coverage as appropriate

Separate Coverages: ) :

Minimum Limit

Policy Number Type of Liability Each Person Each Occurrence

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: The amount of coverage set forth below is a single limit of liability for each occurrence at least equal to the

required minim ums stated above for bodily injury (excluding passengers), property damage, and passenger bodily injury.

Policy Number Amount of Coverage

This policy covers CARGO operations only and excludes passenger liability insurance.

3. The policy or poli cies listed in this certificate insure(s) ( Check One ) : Make and Model FAA or Foreign Flag

Operations conducted with all aircraft operated by the insured Registration No.

Operations conducted with the following types of aircraft:

; Operations with the following aircraft: (Use additional page if necessary) Cessna T 337 D Turbo

, N2337 and Cessna T 337 F Turbo

, N1741M

4. Each policy listed in this certificate meets or exceeds the requirements in 14 CFR Part 205.

XL Specialty Insurance Company Regal Aviation Insurance

(Name of Insurer) (Name of Broker)

101 California Street, Suite 1150 5625 NE Elam Young Parkway, Suite 100

(Address) (Address)

San Francisco, CA 94111 Hillsboro, OR 97124

(City, State, Zip Code) (City, State , Zip Code)

Mark Sacco

(Contact person who can verify the effectiveness of the coverage) (Officer or authorized representativ e)

415

- 837

- 2435 / 415

- 421

- 8118

(Area Code, Phone Number) / (Area Code, Fax Number) (Area Code, Phone Number) / (Area Code, F ax Number)

(Signature, if applicable) (Signature)

June 13, 2012

(Date) (Date)

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