BODILY INJURY AND PROPERTY DAMAGE LIABILITY CERTIFICATE OF INSURANCE (Executed in Triplicate) Filed with Tennessee Bureau of Aeronautics This is to certify, that the _________________________________________________________________ (Name of Company) (hereinafter called company) of _______________________________________________________________ (Home Office Address of Company) has issued to ______________________________ of _____________________________________________ (Name of Common Carrier) (Address of Common) _______________________________________________________ a policy or policies of insurance effective (Carrier) from _____________________ 12:01 a.m. standard time at the address of the insured stated in said policy or policies and continuing until canceled as provided herein, which,

1. (1) Liability for bodily injury to or death of aircraft passengers. A limit for any one passenger of at least seventy-five thousand dollars ($75,000), and a limit for each occurrence in any one aircraft of at least an amount equal to the sum produced by multiplying seventy-five thousand dollars ($75,000) by seventy-five percent (75%) of the total number of passenger seats installed in the aircraft.
2. (2) Liability for bodily injury to or death of persons (excluding passengers). A limit of at least seventy4ive thousand dollars ($75,000) for any one person in any one occurrence, and a limit of at least three hundred thousand dollars ($300,000) for each occurrence.

3. (3) Liability for loss of or damage to property. A limit of at least one hundred thousand dollars ($100,000) for each occurrence.

   1. (a) The minimum limits of liability coverage maintained by an air carrier operator who restricts his operations in air transportation to the carriage of mail or property, or both, shall be those specified in paragraphs (2) and (3) of this section. Whenever requested, the Company agrees to furnish the Bureau a duplicate original of said policy or policies and all endorsements thereon. This certificate may not be canceled without cancellation of the policy to which it is attached. Such cancellation may be effected by the Company or the insured giving thirty (30) days’ notice in writing to the Tennessee Bureau of Aeronautics, such thirty (30) days’ notice to commence to run from the date notice is actually received in the office of the Bureau. Countersigned at ___________________________________________________________________________ (Street Address) (City) (State) (Zip Code) This _______________ day of _______________________ 19 ________. ______________________________________________ Authorized Company Representative Insurance Company File No. ____________________________ (Policy Number) TBA Form A Revised 5/74

Authority: T.C.A. §42-220. Administrative History: Original rule filed June 10, 1974.