AIR CARRIER-CARGO CERTIFICATE OF INSURANCE (Executed in Triplicate) Filed with Tennessee Bureau of Aeronautics (hereinafter called Bureau) This is to certify, that the _________________________________________________________________ (Name of Company) (hereinafter called Company) of _______________________________________________________________ (Home Office Address of Company) has issued to ________________________________________ of ___________________________________ (Name of Carrier) (Address of Carrier) a policy or policies of insurance effective 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, provide cargo insurance covering obligations of at least three thousand dollars ($3,000). Whenever requested, the Company agrees to furnish the Bureau a duplicate original of said policy or policies and all endorsements thereon. This certificate and the endorsement described herein 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 Bureau 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) _______________________________________________ Authorized Company Representative Insurance Company File No. __________________________ (Policy Number) TBA Form C Revised 5/74

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