NOTICE OF CANCELLATION OF AIR CARRIER INSURANCE POLICIES (Executed in Triplicate) Check Type Cancelled BI and PD Cargo Filed with Tennessee Bureau of Aeronautics This is to advise that under the terms of a policy or policies issued to _________________________________________________________________________________ (Name of Air Carrier) of ______________________________________________________________________________________ (Address of Air Carrier I by ______________________________________________________________________________________ (Name of Company) of ______________________________________________________________________________________ (Address) said policy or policies, including any and all endorsements forming a part thereof or certificates issued in connection therewith, is (are) hereby canceled effective as of the day of ____________19 ___, 12:01 a.m., standard time at the address of the Insured as stated in said policy or policies provided such date is not less than thirty (30) days after the actual receipt of this notice by the Bureau. _______________________________________ Signature of Insuror Insurance Company File No. _________________________ TBA Form E Revised 5/74

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