Aircraft Products Liability Application

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Aircraft Products Liability App (XLSIC 12/09) ©, 2009, XL Specialty Insurance Company Page 1 of 5 Aerospace New York - 1 WFC 200 Liberty Street. 3 rd Fl New York, NY 10281 USA Tel: 21 2-915-7000 Fax: 20 3-569-5290 www.xlaerospace.com Aircraft Products Liability Application Please complete all information and sign and date at bottom. This document does not provide any coverage or amend any existing coverage.

Applicant is : (check all that apply) an Individual a Partnership* (explain below) Manufacturer a Corporation Subsidiary* (explain below) Distributor Assembly, Forging or Processing- only to Customer 9s Specifications a Holding Company Other Repair & Service Other GENERAL INFORMATION Applicant 9s Name: Address: City, State, Zip: Telephone: Current Insurance Carrier: Current Coverage Expires: *Name each partner or list all owned subsidiary companies: How long has the applicant been in business? LIMITS OF INSURANCE REQUESTED COVERAGE A: BODILY INJURY OR PROPERTY DAMAGE LIABILITY $ EACH OCCURRENCE AND ANNUAL AGGREGATE COVERAGE B: GROUNDING LIABILITY $ EACH GROUNDING AND ANNUAL AGGREGATE COVERAGES A AND B: COMBINED $ ANNUAL AGGREGATE PRODUCT INFORMATION 1. Describe All Aircraft Products Designed, Manufactured, Assembled, Processed, Repaired/Serviced, or Distributed by the Applicant or its Subsidiaries (submit brochures/website address).

2. Aircraft and/or Aircraft Systems in which ... more. less.

Products are used: 3. Does the Applicant or its Subsidiaries manufacture the entire Product? Yes No If No, describe component part(s) sourced from Others: Aircraft Products Liability App (XLSIC 12/09) ©, 2009, XL Specialty Insurance Company Page 2 of 5 4. Does the Applicant or its Subsidiaries fully assemble the Product? Yes No If No, describe assembly services sourced from Others: 5. Does the Applicant or its Subsidiaries maintain and/or service the Products ? Yes No If Yes, please attach a copy of your standard written service contract. 6. Describe Product Engineering & Testing Controls, Including Names of Outside Firms and Governmental Agencies Involved in Maintai ning Quality Control: 7. List all Products Discontinued and Companies Sold/Terminated for which Coverage is Required: 8. Describe Potential Hazards of all Aircraft Products including if: Flammable, Explosive, Corrosive, Poisonous or Toxic in any C hemical State: 9. Have Any Aircraft Products Ever Been Subject to: (a) Manufacturer 9s Factory Service Bulletin or advisory? Yes No ( b ) Airworthiness Directive? Yes No ( c) Emergency Airworthiness Directive? Yes No \x2 \x2 ( d ) Recall by ( i) A ny Applicant? Yes No (ii) Any Other Firm? Yes No (iii) Any Governmental Agency? Yes No Explain all YES answers (attach separate sheet, if necessary): Please indicate who: Inspects Product Applicant Customer Government Instr ucts Users Applicant Customer Government War ns Users Applicant Customer Government Prepares Operating/Maintenance Manuals Applicant Customer Government 10. Has the Applicant or its Subsidiaries ever been sued or has any claim ever been made against the company with regard to its Aircraft Products? Yes No If Yes, please attach a 10-year loss and provide a detailed summary of the claim or suit whether pending or resolved, including the amount paid and reserved. Loss Run and Details Attached 11. Have there been any other incidents in the past 10 years which could result in a Claim? Yes No Describe: Aircraft Products Liability App (XLSIC 12/09) ©, 2009, XL Specialty Insurance Company Page 3 of 5 Military Fixed Wing $ $ $ $ Rotorcraft $ $ $ $ Missiles $ $ $ $ UAV 9s (unmanned Aerial Vehicle) $ $ $ $ Other $ $ $ $ Foreign Military Fixed Wing $ $ $ $ Rotorcraft $ $ $ $ Missiles $ $ $ $ UAV 9s (unmanned Aerial Vehicle) $ $ $ $ Other $ $ $ $ Military Sub Total $ $ $ $ GRAND TOTAL $ $ $ $ Repair & Servicing of Aircraft and Aviation Products Gross Receipts $ $ $ $ SALES RECEIPTS Estimated Sales Next Year Actual Sales This Year Actual Sales Prior Year Actual Sales Next Prior Year Non-Military Airline $ $ $ $ Fixed Wing-Piston $ $ $ $ Fixed Wing-Turbine (Non Airline) $ $ $ $ Helicopter $ $ $ $ Spacecraft Space Shuttle $ $ $ $ Other $ $ $ $ Non-Military Sub Total $ $ $ $ Describe Repair and/or Servicing Operations: List Principal Customers and Percentage of Sales for Each Cust o mer Name % of Sales Customer Name % of Sales 1. 5. 2. 6. 3. 7. 4. 8. Has the Applicant signed any special warranties or agreements whereby Applicant has indemnified any suppliers or customers? If Yes, please provide copies of these warranties or agreements. Aircraft Products Liability App (XLSIC 12/09) ©, 2009, XL Specialty Insurance Company Page 4 of 5 FRAUD WARNINGS NOTICE TO ARKANSAS APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or be n efit or kno w ingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. NOTICE TO COLORADO APPLICANTS: It is u n lawful to kno w ingly p r ovide false, incomple t e, o r misleading fact s or info r mation to an insur a nce company for the purpose of defra u ding or attempting to defraud th e company. Penalties may include imprisonment, fines, denial o f insurance and civil damages. Any in s urance company or agent of an insurance compan y who knowingly provides false, in c omplete, or misleading facts o r information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claiming with regard to a s ettlement or award payable for insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or an y other person. Pen a lties include imprisonment and/or fines. In addition, an insurer m a y deny insurance benefits if false information materially related to a claim was provided by the applicant . NOTICE TO FLORIDA APPLICANTS: Any pe r son who kno w ingly and with intent to injure, defraud, or d e ceive an y insurance compan y files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the t hird degree. NOTICE TO HAWAII APPLICANTS: For your protection, Hawaii law requires you to be info r med that presenting a fraudulent claim for pa y ment of a loss or benefit is a crime punishable by fines or imprisonment, or both. NOTICE TO KENTUCKY APPLICANTS: Any p e rson who kno w ingly and with intent to d e fraud an y insurance company o r oth e r pe r son files a n application for insurance containing any materially false information or conceals, for the purpose of misleading, information c oncerning any fact material thereto commits a fraudulent insurance act, which is a crime. NOTICE TO KENTUCKY APPLICANTS: Any person who knowingly presents a false or fraudulent cl a im for payment of a loss or benefit or know i ngly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. NOTICE TO MAINE APPLICANTS: It is a crim e to know i ngly p r ovide false, incomplete or misle a ding information to an insurance compan y for t h e purpose of defrauding the company. Penalties may include imprisonment, fines, or denial of insurance benefits. NOTICE TO MARYLAND APPLICANTS: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly and willfully presents false information in an application for insurance is guilty of a crime and ma y be subject to fines and confinement in prison. NOTICE TO NEW JERSEY APPLICANTS: Any person who includes any false or misleading information on an ap p lication for an i n surance policy is subject to criminal and civil penalties. NOTICE TO NEW MEXICO APPLICANTS : Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties. NOTICE TO NEW YORK COMMERCIAL INSURANCE APPLICANTS: Any person who knowingly and with intent to defraud any insurance compan y or other pe r son files an application for insurance or statement of c laim containing an y materiall y false information, or concea l s f o r the purpose o f misleading, information concerning an y fact material thereto, com m its a fraudulent insurance act, w h ich is a crime, and shall a l so be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. NOTICE TO NEW YORK APPLICANTS FOR AUTOMOBILE INSURANCE: An y person who knowingly makes or knowingly assists, abets, solicits or conspires with another to make a false repo r t of the theft, destruction, damage or conversion of any motor vehicle t o a la w enforcement agency, the department of motor vehicles or an insurance company, commits a fraudulent insurance act, which is a crime, and shall also be s ubject to a civil penalty not to exceed five thousand dollars and the value of the subject motor vehicle or stated claim for each violation. NOTICE TO NEW YORK APPLICANTS FOR FIRE INSURANCE: Any person who knowingly and with intent to defraud a n y ins u rance compan y or other person files an application for insurance containing an y false information, or conceals for the purpose of misleading, in f ormation concerning an y fact material thereto, commits a fraudulent insura n ce act, w h ich is a crime. The p roposed insure d affirms that th e foregoing information is true and agrees that these applications shall constitute a part of any policy issued whether attached or not and that any willful concea lment or misrepresentation of a material fact or circumstances shall be grounds to rescind the insurance policy. NOTICE TO OHIO APPLICANTS: Any person who, with inte n t to defra u d o r kn o wing that he is facilitating a fra u d against an insurer, submits a n application or files a claim containing a false or deceptive statement is guilty of insurance fraud. NOTICE TO OKLAHOMA APPLICANTS: WARNING : Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. NOTICE TO PENNSYLVANIA APPLICANTS: Any person who knowingly and with intent to defra u d any insurance company or other person files an application for insurance or stat e ment of cl a im containing an y materially false information or conceals for the p u rpose of misl e ading, informatio n concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. NOTICE TO PENNSYLVANIA APPLICANTS FOR AUTO INSURANCE: Any person who knowingly and with intent to injure or defraud any insurer files an application or claim containing an y false, incomplete ormisleading information shall, upon c o nviction, be subject to imprisonment for up to seve n years and the payment of a fine of up to $15,000. NOTICE TO PUERTO RICO APPLICANTS: Any person who knowingly and with the intention to defraud includes false information in an application for insurance or file, assist or abet in the filing of a fra u dulent claim to obtain payment of a loss or other benefit, or files more than one claim for the same loss or damage, commits a felony and if found guilty shall be punished for each violation with a fine of no less than five thou sands dollars ($5,000), not to Aircraft Products Liability App (XLSIC 12/09) ©, 2009, XL Specialty Insurance Company Page 5 of 5 exceed ten thousands dollars ($10,000); or imprisoned for a fixed term of three (3) years, or both. If aggravating circumstanc es exist, the fixed jail term may be increase d to a maximum of five (5) years; and if mitigat i ng circumstances are present, t h e jail term ma y be reduced to a minimum of tw o (2) years. NOTICE TO RHODE ISLAND APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefitor knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confi nement in prison. NOTICE TO TENNESSEE APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance compan y for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits. NOTICE TO TENNESSEE FOR WORKERS COMPENSATION: It is a crime to know i ngly provide false, incomplete or misleading information toany party to a workers compensation transaction for the purpose of committing fraud. Penalties include imprisonment, fines and deni al of insurance benefits. NOTICE TO UTAH APPLICANTS: Workers Compensation: Any person who knowingly presents false or fraudulent underwriting information, files or causes to be fi l ed a false or fraudulent cl a im for disability compensation or medical benefits, or su b mits a false or f r audulent report or billing for heal t h care fees or other professional services is guilty of a crime and may be subject to fines and confinement in state prison. NOTICE TO VIRGINIA APPLICANTS: It is a cri m e to kno w ingly provide false, incomplete or misleading informatio n to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits . NOTICE TO WAHSINGTON APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits. NOTICE TO WEST VIRGINIA APPLICANTS: Any person who knowingly p r esents a false or fr a udulent claim f o r payment of a loss or benefit o r knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confi nement in prison NOTICE TO ALL OTHER STATES: Any person who knowingly and willfully presents false information in an applic a tion for insurance may be guilty of insurance fraud and subject to fines and confinement in prison. (Fraud Language Revised 12/07/09) THE APPLICANT REPRESENTS TH A T THE ABOVE ST A TEMENTS AND F A CTS ARE TRUE AND TH A T NO M A TERIAL FA C TS H A VE BEEN SUPPRESSED OR MISSTATED . COMPLETION OF THIS FORM DOES NOT BIND COVERAGE. APPLICANT 9S ACCEPTANCE OF THE CO M PANY 9S QUOTATION IS REQUIRED PRIOR TO BINDING COVERAGE AND POLICY ISSUANCE. ALL WRITTEN STATEMENTS AND MATERIALS FURNISHED TO THE COMPANY IN CONJUNCTION WITH THIS APPLICATION ARE HEREBY INCORPORATED BY REFERENCE INTO THIS APPLICATION AND MADE A PART HERE OF. I understand that by signing below, I am agreeing that: all statements on this application are complete and true to the best of my knowledge; no information has been suppressed or withheld; no insurer has cancelled or refused to renew this insurance; the information herei n and the truthfulness thereof will be the basis of any insurance provided by the company; this application does not bind the applicant or the company to provide any insurance; any person who knowingly and with intent to defraud any insurance company or other person files an application for i nsurance or statement of claim containing any materially false information, conceals for the purpose of misleading, information concerning any fact m aterial thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars an d the stated value of the claim for each such violation. Applicant: Title: Applicant 9s Signature: Date: Producer: State / License No.: / Address: City: State: Zip : Phone: - - Fax: - - SaveAs

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