REQUEST FOR INDEMNIFICATION.doc

SOLICITATION NO: HTC711-11-R-C002

SAMPLE FORMAT

To: Contracting Officer

1. XXX Air Carrier, Inc., requests that it be indemnified pursuant to Public Law 85-804 for loss or damages caused by unusually hazardous risks as described in, and under the conditions prescribed by Solicitation Number HTC711-10-R-C001.

2. XXX Air Carrier may be exposed to unusually hazardous risks while performing mission and related services for the DoD due to cancellation, prohibitive price escalations and/or coverage limitations of its commercial or government-provided insurance, to include war risk insurance. XXX Air Carrier’s hull and liability policies exclude coverage for enumerated war risks. For its ordinary operations, it purchases war risk coverage that satisfies this need. However, this coverage may not be available for operations in support of the DoD because it is subject to cancellation by the insurer on X days notice and such cancellation is likely in time or regions of crisis or during CRAF activation [and/or] [the coverage excludes all operations as part of the CRAF when it is activated] [and/or] [the coverage does not include flights to or over [Iraq], [Burundi], [Libya], [etc] unless the insurer expressly consents in advance.] In addition, the commercial or FAA war risk coverage available may not be precisely coextensive with the unusually hazardous risks described in the solicitation. (e.g. damage caused by hostile detonation of nuclear weapons).

3. A summary of all insurance coverage carried by XXX Air Carrier applicable to the specified unusually hazardous risks is attached.

4. The controlling or limiting factors that determine the amount of financial protection XXX Air Carrier provides and maintains include the risks to which it is exposed in the regular course of operations; the value of its assets; the availability, cost, and terms of insurance coverage; and its obligations to secure type and amounts of insurance required by regulatory agencies and third parties such as lessors. The amounts and types of insurance maintained are consistent with prevailing industry practices for commercial air carriers. (Tailor as necessary to describe carrier’s insurance practices).

5. XXX Air Carrier’s insurance programs in general or aggregate are not subject to approval and have not been approved by any government agency. (This is normally the case. Carrier should verify and change as necessary.) It has no indemnification agreement covering similar risks under any other government program. It has applied for or obtained FAA 443 Non-Premium Insurance coverage as required or appropriate.

6. [XXX Air Carrier is not a division or subsidiary of a parent corporation.] [ XXX Air Carrier is a {division} {subsidiary} {other} of ___________ {which provides/carries no insurance coverage bearing on the risks for which indemnification is sought} {other}].

Signature of Official Authorized to Bind Offeror Attachment A: Insurance Table:

TYPE OF INSURANCE

INSURER’S NAME AND ADDRESS

PER OCCURRENCE, ANNUALLY &

OTHER

HULL

$xxx,xxx,xxx annually or {$x,xxx,xxx per aircraft (12 B747-100 aircraft)}

{Spares}

$xxx,xxx,xxx annually or

{$x,xxx,xxx per aircraft (12 B747-100 aircraft)}

$xxx,xxx,xxx annually or

{$x,xxx,xxx per aircraft (12 B747-100 aircraft)}

*Link to FAR website http://farsite.hill.af.mil/reghtml/regs/far2afmcfars/fardfars/far/50.htm#P171_26249

Attachment A: Insurance Table:

PER OCCURRENCE, ANNUALLY &

LIABILITY

{Bodily Injury Excluding Passengers}

{None}

$x,xxx,xxx per person &

$xx,xxx,xxx annually

{Passenger Bodily Injury}

{None}

{Property Damage}

{None}

{Passenger Crew and Property Liability}

{None}

{None}

*Link to FAR website http://farsite.hill.af.mil/reghtml/regs/far2afmcfars/fardfars/far/50.htm#P171_26249

TYPE OF INSURANCE

EXCLUSIONS

DOLLAR LIMITS

800 Independence Avenue SW

Washington DC 20591} {other}

{PX-XXX-XX-XX}

{other}

800 Independence Avenue SW

Washington DC 20591

WORKER’S COMPENSATION

& EMPLOYER’S LIABILITY INSURANCE INCLUDING DEFENSE BASE ACT (DBA) INSURANCE**

$x,xxx,xxx disease limit

$x,xxx,xxx policy limit

*Link to FAR website http://farsite.hill.af.mil/reghtml/regs/far2afmcfars/fardfars/far/50.htm#P171_26249 ** DBA not subject to Indemnification but required per Contract Clauses FAR 52.228-3, 52-228-4, and 52-228-5 http://farsite.hill.af.mil/reghtml/regs/far2afmcfars/fardfars/far/52_227.htm#P594_136140

TYPE OF INSURANCE

INSURER’S NAME AND ADDRESS

ANY OTHER APPLICABLE INSURANCE COVERAGE:

Defense Base Act {$x,xxx,xxx amount of self-insurance after which reinsurance by AIG appli

Any type of self-insurance and what you self-insure for

Any other insurance which extends to air operations

*Link to FAR website http://farsite.hill.af.mil/reghtml/regs/far2afmcfars/fardfars/far/50.htm#P171_26249

Exhibit A (for Multiple insurers).

This list is coverage for our {Hull All Risks (ground & flight)} {Spares} {Leased Engines} {Bodily Injury Excluding Passengers} {Passenger Bodily Injury} {Property Damage} {Passenger Crew and Property Liability} {other}

Global Aviation

51 John F. Kennedy Parkway

Short Hills NJ 07078

The Underwriters at Lloyd’s of London

Aviation and Aerospace Practice

Tower Place

London EC3R 5BU

United Kingdom

AIG Aviation

100 Colony Square

PO Box 448

Atlanta GA 30361

The XL Specialty Insurance Company through XL

1111 Chapala Street, Suite 300

Santa Barbara, CA 93101

Exhibit B

DEDUCTIBLES

HULL POLICIES:

DEDUCTIBLE

{Wide Body Aircraft}

$x,xxx,xxx

{Narrow Body Aircraft}

$xxx,xxx

{B747-100}

{While the aircraft is in motion}

$x,xxx,xxx

{While the aircraft is not in motion}

{other}

$xx,xxx,xxx

Spares

$xx,xxx

Leased Engines

LIABILITY POLICIES:

{None }

{None}

{other}

$x,xxx

PREMIUM WAR RISK INSURANCE

None

CHAPTER 443 NON-PREMIUM

WORKER’S COMPENSATION

& EMPLOYER’S LIABILITY INS

{None} {Other}

OTHER TYPES OF INSURANCE

xxxxxx

$xx,xxx Exhibit C - Exclusions:

List exclusions here and/or attach the page(s) out of your insurance policy that talks about the exclusions to your policy or pull all exclusionary clauses and attach them as an Exhibit.

HULL POLICIES:

See attached pages from our policy including the, {War, Hi-Jacking and Other Perils Exclusion Clause}, {Nuclear Risks Exclusion Clause}, {Geographical Exclusions Clause}, {other}

LIABILITY POLICIES:

See attached pages from our policy including the {Bodily Injury Exclusion} {Personal Injury Exclusion} {Property Damage Exclusion} {Physical Damage Exclusion} {Terrorism Exclusion} {War, Hi-Jacking and Other Perils Exclusion Clause}, {Nuclear Risks Exclusion Clause}, {Geographical Exclusions Clause}, {other}

{THIRD PARTY WAR RISK} OR {PREMIUM WAR RISK INSURANCE}:

Exclusions include: CRAF activation or CRAF-like missions covered by FAA 443 Non Premium Insurance Program

FAA NON-PREMIUM INSURANCE:

Exclusions include: None

WORKER’S COMPENSATION INSURANCE:

Exclusions include: {Intoxication of the worker, by the influence of narcotic drugs, barbiturates or stimulates not prescribed by a physician}; {willful intention of the worker to injure or kill himself or another}; {willful disregard of safety rules and regulations}, {other}

OTHER APPLICABLE INSURANCE:

Exclusions include:

FAR 50.104-3 (a) (1) (iii) (A)*

FAR 50.104-3 (a) (1)

(iii) (B)*

FAR 50.104-3 (a) (1) (iii) (D)*

FAR 50.104-3 (a) (1) (iii) (E)*

FAR 50.104-3 (a) (1) (iii) (C)*

FAR 50.104-3 (a) (1) (iii) (B) and (F)*

And (F)

PAGE

Attachment 7 1 July 2011