B08.02 DD Form 2400 Cert of Insurance.pdf

CIVIL AIRCRAFT CERTIFICATE OF INSURANCE

(To be completed only by the insurer or an authorized representative.)

Please read Privacy Act Statement and Instructions on back before completing.

1. TODAY'S DATE

(YYYYMMDD)

OMB No. 0701-0050

The public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, Executive Services Directorate, Information Management Division, 1155 Defense Pentagon, Washington, DC 20301-1155 (0701-0050). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.

PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ORGANIZATION. SEND COMPLETED FORM TO THE ADDRESS IN NOTE 2 ON BACK.

2. INSURER 3. INSURED (User)

a. NAME a. NAME

b. ADDRESS (Street, City, State and ZIP Code) b. ADDRESS (Street, City, State and ZIP Code)

4. AIRCRAFT POLICY DATA

POLICY

NUMBER(S)

a.

EFFECTIVE DATE

(YYYYMMDD) b.

EXPIRATION DATE

(YYYYMMDD) c.

GEOGRAPHICAL AREA OR LIMIT OF

POLICY COVERAGE

d.

AIRCRAFT REGISTRATION

NUMBER(S)

e.

5. AIRCRAFT LIABILITY COVERAGE

AMOUNT OF

INSURANCE FOR

(Must be stated in U.S. Dollars)

BODILY INJURY

a.

PROPERTY DAMAGE

b.

PASSENGER

c.

(1) EACH

PERSON

(2) EACH

ACCIDENT

6. SINGLE LIMIT (If the aircraft are insured with a single limit of liability, the amount of the single limit must be equal to or greater than the combined amount of bodily injury, property damage, and passenger liability specified in applicable military regulations listed iin NOTE 1 on back.) (Must be stated in U.S. Dollars.)

7. EXCESS LIABILITY (If the aircraft are insured by a combination of primary and excess policies, the combined amounts of bodily injury, property damage, and passenger liability, respectively must be equal to or greater than those specified in applicable military regulations listed in NOTE 1 on reverse.) (NOTE: When this entry is completed, include primary policy numbers or amounts over which the excess applies. Show whether excess applies to bodily injury, property damage, or passenger liability.) (Must be stated in U.S. Dollars.)

8. PROVISIONS OF AMENDMENTS OR ENDORSEMENTS OF LISTED POLICY(IES)

a. The insurer waives any right of subrogation the c. If the insurer cancels or reduces the amount of insurance afforded under the listed insurer may have against the United States by reason of policy(ies), the insurer shall send written notice of the cancellations or reduction to the any payment under the policy(ies) for damage or injury applicable address listed in NOTE 2 on reverse, by registered mail at least thirty days which might arise out of or in connection with the in advance of the effective date of cancellation; the policy must state that any insured's use of any military installation or facility. cancellation or reduction will not be effective until at least thirty days after such notice is sent, regardless of the effective date specified therein.

b. The insurance afforded by the policy(ies) encompasses the liability assumed by the insured under d. If the insured requests cancellation or reduction, the insurer shall notify the DD Form 2402, Hold Harmless Agreement, which is applicable addressee listed in NOTE 2 on reverse immediately upon receipt of such incorporated herein by reference. request.

9. CERTIFICATION (To be completed by Authorized Insurance Official)

I certify that insurance is in effect as stated in this certificate and that I have authorization to issue this certificate for and on behalf of the insurer. This certificate is valid until the expiration date(s) shown in item 4 unless canceled or superseded in writing, in accordance with items 8c and d.

a. TYPED NAME OF INSURER'S AUTHORIZED REPRESENTATIVE b. SIGNATURE (Blue Ink)

c. TITLE d. TELEPHONE NUMBER (Include Area Code)

DD FORM 2400, JAN 2008 PREVIOUS EDITION IS OBSOLETE. Adobe Professional 7.0

PRIVACY ACT STATEMENT

AUTHORITY: 49 U.S. Code, Section 44502(d).

PRINCIPAL PURPOSE(S): Provides an insurance company's certification of current third party insurance liability for an individual or corporation that operates civil aircraft at military aviation facilities.

ROUTINE USE(S): None.

DISCLOSURE: Voluntary; however, failure to provide this information will result in an individual or corporation being unable to operate civil aircraft into military aviation facilities.

INSTRUCTIONS FOR COMPLETION OF DD FORM 2400

This form is to be completed only by the insurer or authorized representative.

1. Complete all applicable items. Continue below if additional space is required. 4. All items are self-explanatory except:

Refer to item number(s).

Item 4d - List the geographical area or

2. Sign original of this form and send to the applicable address listed in NOTE 2 geographical limits within which the below. Send a copy to each approving authority to which a DD Form 2401 is policy(ies) apply. submitted for approval. All copies of form must be signed with original signatures. Signature stamps, camera copied signatures, or any type facsimile signatures are unacceptable. Item 4e - The statement "All aircraft owned or operated by the insured," is acceptable and

3. This form is available under DefenseLink, Publications. preferred.

IF ADDITIONAL SPACE IS REQUIRED, CONTINUE HERE (Refer to item number)

ARMY NAVY AIR FORCE

NOTE 1

AR 95-2

Can be viewed at: http://books.army.mil/ cgi-bin/bookmgr/Shelves

32 CFR 766

Can be viewed at: http://calp.navfac.navy.mil

AFI 10-1001

Can be viewed at: http://afpubs.hq.af.mil

NOTE 2

COMMANDER

USAASA, ATTN: ATAS-AS

BLDG 1466

9325 GUNSTON RD, SUITE N319

FT BELVOIR, VA 22060-5582

(703) 806-0686

COMMANDER NAVAL

FACILITIES ENGINEERING

COMMAND CODE: REAT

WASHINGTON NAVY YARD

1322 PATTERSON AVE. S.E., SUITE 1000

WASHINGTON, DC 20374-5065

(202)685-9202

HQ USAF/A30-AC

1480 AIR FORCE PENTAGON RM 5E857

WASHINGTON, DC 20330-1480

(703) 697-5967

DD FORM 2400 (BACK), JAN 2008

http://books.army.mil/ http://calp.navfac.navy.mil/ http://afpubs.hq.af.mil/