Atch 9 - Indemnification Request Template_v2.pdf

HTC711-24-R-CC01

Attachment 9

REQUEST FOR INDEMNIFICATION

To: Contracting Officer

1.____________________, requests that it be indemnified pursuant to Public Law 85-804 for loss or damage caused by unusually hazardous risks as described in, and under the conditions prescribed by Solicitation Number HTC711-24-R-CC01.

2. ___________________may be exposed to unusually hazardous risks while performing missions 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. _______________ 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 ______ days’ notice and such cancellation is likely in time or regions of crisis or during CRAF activation_______ the coverage excludes all operations as part of the CRAF when it is activated________ the coverage does not include flights to or over ___________________, 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.

3. A summary of all insurance coverage carried by _________________applicable to the specified unusually hazardous risks is attached.

4. The controlling or limiting factors that determine the amount of financial protection _____________________ 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.

5. __________________ 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 FAA non-premium insurance coverage issued by the FAA under Chapter 443 of title 49, U.S. Code.

6. _____________________ _________________________ which provides/carries no insurance coverage bearing on the risks for which indemnification is sought.

7. In accordance with, FAR 50.104-3(a)(2), if the dollar value of the contractor’s insurance coverage varies by 10 percent or more from that stated in an indemnification request submitted in accordance with paragraph (a)(1) of this subsection, or if other significant changes in insurance coverage occur after submission and before approval, the contractor shall immediately submit to the contracting officer a brief description of the changes.

Signature of Official Authorized to Bind Offeror Date

Attachment A: Insurance Table:

TYPE OF

INSURANCE

INSURER’S

NAME AND

ADDRESS

POLICY

#S

POLICY

DATES

DEDUCTIBLES EXCLUSIONS DOLLAR LIMITS

PER OCCURRENCE,

ANNUALLY &

OTHER

HULL

Hull All Risks (ground & flight)

See Exhibit A See Exhibit A

See Exhibit B See Exhibit C ____________ per occurrence _____________ annually or _____________ per aircraft

Spares See Exhibit A See Exhibit A

See Exhibit B See Exhibit C ____________ per occurrence _____________ annually or _____________ per aircraft

Other See Exhibit A See Exhibit A

See Exhibit B See Exhibit C ____________ per occurrence _____________ annually or _____________ per aircraft

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

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)* http://farsite.hill.af.mil/reghtml/regs/far2afmcfars/fardfars/far/50.htm#P171_26249

Attachment A: Insurance Table:

TYPE OF

INSURANCE

INSURER’S

NAME AND

ADDRESS

POLICY

#S

POLICY

DATES

DEDUCTIBLES EXCLUSIONS DOLLAR LIMITS

PER OCCURRENCE,

ANNUALLY &

OTHER

LIABILITY

Bodily Injury Excluding Passengers

See Exhibit A See Exhibit A

See Exhibit C ______________ per occurrence, ______________ per person & ______________ annually

Passenger Bodily Injury

See Exhibit A See Exhibit A

See Exhibit C ______________ per occurrence, ______________ per person & ______________ annually

Property Damage See Exhibit A See Exhibit A

See Exhibit C ______________ per occurrence, ______________ per person & ______________ annually

Passenger Crew and Property Liability

See Exhibit A See Exhibit A

See Exhibit C ______________ per occurrence, ______________ per person & ______________ annually

Other See Exhibit A See Exhibit A

See Exhibit C ______________ per occurrence, ______________ per person & ______________ annually

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

FAR 50.104-3 (a) (1)

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

FAR 50.104-3 (a)

(1) (iii) (D)*

FAR 50.104-3

(a) (1) (iii) (E)*

Attachment A: Insurance Table:

TYPE OF

INSURANCE

INSURER’S

NAME AND

ADDRESS

POLICY

#’S

POLICY

DATES

DEDUCTIBLES EXCLUSIONS DOLLAR LIMITS

PER OCCURRENCE,

WAR RISK

INSURANCE OR

THIRD PARTY WAR

RISK LIABILITY

None See Exhibit C ______________ per occurrence, ______________ per person & ______________ annually

FAA 443 NON-

PREMIUM

Federal Aviation Administration 800 Independence Avenue SW Washington DC 20591

None None

WORKER’S

COMPENSATION

& EMPLOYER’S

LIABILITY

INSURANCE

INCLUDING

DEFENSE BASE ACT

(DBA) INSURANCE**

See Exhibit C _______________ each accident _______________ disease limit _______________ 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

FAR 50.104-3 (a) (1)

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

FAR 50.104-3

(a) (1) (iii) (D)*

FAR 50.104-3

(a) (1) (iii) (E)*

Federal Aviation Administration 800 Independence Avenue

SW

Washington DC 20591 http://farsite.hill.af.mil/reghtml/regs/far2afmcfars/fardfars/far/52_227.htm#P594_136140

Attachment A: Insurance Table:

TYPE OF

INSURANCE

INSURER’S

NAME AND

ADDRESS

POLICY

#S

POLICY

DATES

DEDUCTIBLES EXCLUSIONS DOLLAR LIMITS

PER OCCURRENCE,

ANY OTHER

APPLICABLE

INSURANCE

COVERAGE:

Defense Base Act Self-Insured __________ annual dollar limit after which reinsurance DBA policy from AIG applies

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

FAR 50.104-3 (a) (1)

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

FAR 50.104-3

(a) (1) (iii) (D)*

FAR 50.104-3

(a) (1) (iii) (E)*

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

N/A N/A N/A N/A

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}

Insurer Policy Number % share of policy

Total 100%

Exhibit B

DEDUCTIBLES

HULL POLICIES: DEDUCTIBLE

LIABILITY POLICIES: DEDUCTIBLE

PREMIUM WAR RISK INSURANCE DEDUCTIBLE

None None

CHAPTER 443 NON-PREMIUM DEDUCTIBLE

None None

WORKER’S COMPENSATION DEDUCTIBLE

& EMPLOYER’S LIABILITY INS

OTHER TYPES OF INSURANCE DEDUCTIBLE

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

LIABILITY POLICIES:

See attached pages from our policy including the

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

Exclusions include: Civil air missions awarded individually to those specified operators pursuant to USTRANSCOM Solicitation HTC711-24-R-C001 or CRAF activation missions covered by FAA 443 Non Premium Insurance Program.

FAA NON-PREMIUM INSURANCE:

Exclusions include:

WORKER’S COMPENSATION INSURANCE:

Exclusions include:

OTHER APPLICABLE INSURANCE:

Exclusions include: