Appendix A to Part 198 - Form of Application Named in § 198.9

United States of America Department of Transportation Federal Aviation Administration Application for Aviation Insurance

Application is made for aviation insurance, pursuant to Title XIII of the Federal Aviation Act of 1958, as amended, and in accordance with all provisions of law and subject to all limitations thereof, on the aircraft described in the attached “Schedule of Aircraft,” with the understanding that this application does not commit the Government to any liability or make the applicant liable for any premium or fees unless insurance is effected by the Federal Aviation Administrator.

Name of Applicant Address Basis of Insurance

( ) Insurance with premium

( ) Insurance without premium:

Contracting Federal Agency Date and Number of Contract Hull

Amounts set forth in the attached “Schedule of Aircraft” as representing the amount of hull insurance desired for each such aircraft shall not exceed the amount in effect on the date of this application, by which the applicant has insured or self-insured that aircraft.

Liability, Exclusive of Cargo

The type and amounts of coverage required for the aircraft described in the attached “Schedule of Aircraft” shall be indicated and the limits of liability for each such coverage shall be specified in the schedule, but such limits shall not exceed the corresponding amounts in effect on the date of this application by which the applicant has insured or self-insured against liability.

Liability of Cargo

Limits of liability desired for each of the aircraft described in the attached “Schedule of Aircraft” shall be specified.

General

Insurance shall attach no earlier than the commercial insurance terminates or at such time as may be specified in the policy.

If application is for insurance with premium, the rate of premium and the amount of any deductible shall be fixed by the Federal Aviation Administrator, acting for the Secretary of Transportation. The registration fee for insurance without premium is $200 per aircraft listed on the “Schedule of Aircraft” and is not returnable unless application is rejected. Registration fees are due upon application or revision of the “Schedule of Aircraft” adding aircraft and are payable by check to the Federal Aviation Administration.

The application shall be accompanied by copies of any commercial insurance policy and any company plan of self-insurance applicable to the aircraft listed in the “Schedule of Aircraft.”

The “Schedule of Aircraft” attached to policies without premium may be revised from time to time by agreement of the Federal Aviation Administrator and the insured and with the approval of the Federal agency on whose behalf contract air services are to be performed, to add aircraft or to add contracts.

The application also shall be accompanied by a statement which shall be considered to be incorporated in the application and to form a part thereof, and which shall be signed by the same corporate official who signs the application on behalf of the applicant. The statement shall show that the applicant:

(a) Controls and operates the aircraft listed in the attached “Schedule of Aircraft,” and if application is for insurance without premium, has committed such aircraft to the above indicated contract(s);

(b) Is maintaining and has maintained during the 6-month period preceding this application (or since the aircraft was acquired if acquired during the 6-month period) insurance, including demonstrable self-insurance, covering possible injury, loss or damage in amounts which equal or exceed the insurance coverages requested in the application; and

(c) Cannot obtain insurance of the type requested on reasonable terms and conditions from companies authorized to engage in an insurance business in a State of the United States or the District of Columbia, or has partial commercial insurance coverage, but is unable to obtain the additional needed insurance of the type requested on reasonable terms and conditions from such commercial sources;

Verification shall include evidence of premium rate history, the names of the commercial insurance carriers which have been contacted and the premium rates quoted by such carriers which applicant considers not reasonable, and any conditions or limitations which those carriers would impose or have imposed, such as evidence of cancellation or notice of cancellation, which would cause their insurance to be inapplicable to some or all of the operations by aircraft listed in the “Schedule of Aircraft.”

If the application is for insurance with respect to a foreign-flag aircraft, it shall be accompanied by the statement setting forth the registration number(s) of the aircraft, the nationality of registration, and the name of the owner or lessee.

The insurance applied for hereunder shall not cover risks to persons or property engaged or transported exclusively in operations between two points in the United States as defined in section 101(41) of the Federal Aviation Act of 1958, as amended (49 U.S.C. 1301 (41)).

Applicant warrants that the particulars herein are true and complete to the best of his or her knowledge and that no information has been withheld or suppressed.

Applicant agrees that this application, including all attachments hereto and all revisions of the “Schedule of Aircraft” hereinafter accepted by the Government and the terms and conditions of the form of policy prescribed by the Federal Aviation Administrator, acting for the Secretary of Transportation, will constitute the basis of any contract between him or her and the United States of America.

Applicant By (Name and Title) Date____________ Schedule of Aircraft Hull InsuranceMake, model, and configuration (passenger, cargo, or convertible)FAA identification No. or equivalentAmount of hull insurance desired for each aircraftAmount for which each aircraft is currently insured (including self-insurance)Loss payee Liability Insurance(Exclusive of cargo)Amount requested per occurrenceAmount of insurance (including self-insurance) in effect per occurrence Liability to cargoAmount requestedAmount of insurance (including self-insurance) in effect per occurrence