6410 U.S. Air Carriers - Certificate of Insurance

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Department of Transportation, Office of Aviation Analysis, X-56, 400 7 St., SW., Washington, D.C. 20590. According to the
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Office of the Secretary
of Transportation

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 - 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, AFS-260, 800 Independence Ave., S.W., Washington,
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
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Transportation, Air Carrier Fitness Division, X-56, 400 7 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
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form with the Federal Aviation Administration, Alaskan Region Hq., AAL-230, 222 W. 7 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 and FAA Certificate number of Insured U.S. 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 “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 U.S. COMMUTER AIR CARRIERS) WITH PART 298 AUTHORITY ONLY:
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

Bodily Injury Liability
(Excluding Passengers)
Passenger Bodily Injury

$ 75,000 $300,000
$ 75,000 $75,000 x 75% of
total number of
passenger seats
installed in aircraft

_________________________

Property Damage

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 No.__________________________________

OST Form 6410

$100,000

Amount of Coverage_________________________________

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

B. U.S. COMMUTER AIR CARRIERS OR CERTIFICATED 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:
Policy No.

Type of Liability

__________________

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

__________________

Minimum Limit
Each Occurrence

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 No.__________________________________

Each person

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

Separate Coverages:
Policy No.

Type of Liability

__________________

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

__________________

Minimum Limit
Each Occurrence

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 No.__________________________________

Each person

Amount of Coverage__________________________

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)