OST Form 6411

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 suggestions for reducing this burden, please direct your comments to: U.S. Department of Transportation, Office of Aviation Analysis, X-56, 400 7th 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  

FOREIGN AIR CARRIERS - CERTIFICATE 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, Air Transportation Div., AFS-260, 800 Independence Ave., SW., Washington, DC 20591. (See EXCEPTION below.)

EXCEPTION: 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), 1200 New Jersey Ave., SE, 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):

 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):

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):

 Separate Coverages: Minimum Limit                  

Policy No. Type of Liability Each person Each Occurrence    

__________________ 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):

 Separate Coverages: Minimum Limit                   

Policy No. 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: 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):

 Separate Coverages: Minimum Limit                     

Policy No. Type of Liability Each person Each Occurrence    

__________________ 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): Make and Model FAA or Foreign Flag

Registration No.      

 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)