OLD REPUBLIC INSURANCE COMPANY

1 AIRCRAFT HULL & LIABILITY INSURANCE APPLICATIONS treet:City:Zip Code:State:Applicant Name:Page 1 of 5UW001 (01/16)Business of Applicant:Policy No. (if known)toEffective fromLiability Coverage (for Aerial Applications, complete Chemical Liability in Aerial Section)Each PersonEach OccurenceBodily Injury - Excluding Passengers$$Property Damage$Passenger Liability$$Single Limit Bodily Injury $$Medical Expenses $$$$Excluding Passengers and Property DamageIncludingExcluding CrewHours flown last 12 months:Est. hours flown next 12 months:Est. passenger load next 12 months:Engine Make/Type:Engine Hours:Since NewSince Major OverhaulZip Code:State:City:Address:Lienholder Name/Attn:Applicant is:Sole OwnerLesseeOwner subject to LienOtherexplain:Aircraft based at (identify):Runway Length in feet:PublicPrivatePavedHangardAngle of attack indicatorTCAS / TISTAWS / GPWSA ircraft Equipment:If operated for hire, percentage of use:Passenger:Cargo:Instruction:Rental:% %%%%Other:Amount of Lien (excluding interest and charges): $Breach of Warranty Required?

2 :YesNoDescribe any STC's, modifications or unrepaired damage:If Airworthiness Certificate is other than Standard, please identify category:DeductiblesIn MotionNot-In-MotionIngestionAll Risk Ground and FlightAll Risk Ground Not In FlightAll Risk Ground OnlyAll Bodily Injury Limited to:Other Liability:Agreed ValuePhysical Damage CoverageMake/ModelFAA No.: Year:NewUsedLandSeaAmphibiousSeating Capacity:Describe any STC's, modifications or unrepaired damage:If Airworthiness Certificate is other than Standard, please identify category:DeductiblesIn MotionNot-In-MotionIngestionAll Risk Ground and FlightAll Risk Ground Not In FlightAll Risk Ground OnlyAgreed ValuePhysical Damage CoverageMake/ModelFAA No.

3 : Year:NewUsedLandSeaSeating Capacity:$$$$$$$$Aircraft 1 Aircraft 2 Passenger Bodily Injury Limited to:OLD REPUBLIC INSURANCE COMPANY1990 Vaughn Road, Suite 350 Kennesaw, Georgia 30144 AmphibiousLiability Coverage (for Aerial Applications, complete Chemical Liability in Aerial Section)Each PersonEach OccurenceBodily Injury - Excluding Passengers$$Property Damage$Passenger Liability$$Single Limit Bodily Injury $$Medical Expenses $$$$ Passenger Carrying for Hire (Charter/Air Taxi)Corporate-Executive (flown by professional pilots employed for this purpose)

4 Pleasure orAir Ambulance / EMSB usiness (not flown by professional pilots employed for this purpose)Aerial PhotographyFlying ClubSightseeingAerial Application (see Aerial Application section)List other uses not indicated:Freight Carrying (for hire)Pipeline / Powerline PatrolInstructionElectronic News Gathers / Traffic WatchBanner TowingYesNoWill aircraft be operated at other than paved airports?Will aircraft be operated outside the 48 contiguous states of the , surface and length of runway:Where, purpose and length of frequency:If 'Yes', explain:YesNoDoes applicant or employees (including employee pilots) use non-owned aircraft?

5 Model Aircraft:Use(s):Hours of use per year:YesNoDo you request a certificate of INSURANCE ?YesNoDo you charter aircraft on COMPANY business?If your aircraft is managed by others, please identify the manager:If 'Yes', explain:YesNoAre any turbine aircraft operated with a single pilot crew Part 135?Who employs your pilots?:Name and describe your relationship to the Named Insured:YesNoDoes applicant hangar, service, repair or crew other aircraft?If 'Yes', explain:1:List the pilots who operate the insured aircraft. Please complete a Pilot History Form for each :3:4:5:6:If 'Yes', explain:YesNoAre any aircraft registered under other names than applicant's name?

6 Min Liability Limit you will accept from the operator: $Purpose of UseHours flown last 12 months:Est. passenger load next 12 months:Est. hours flown next 12 months:Engine Make/Type:Engine Hours:Since NewSince Major OverhaulZip Code:State:City:Address:Lienholder Name/Attn:Applicant is:Sole OwnerLesseeOwner subject to LienOtherexplain:Aircraft based at (identify):Runway Length in feet:PublicPrivatePavedHangarAngle of attack indicatorTCAS / TISTAWS / GPWSA ircraft Equipment:If operated for hire, percentage of use:Passenger:Cargo:Instruction:Rental:% %%%%Other:Amount of Lien (excluding interest and charges): $Breach of Warranty Required?

7 :YesNoFor additional aircraft please attach an "Aircraft Fleet Addendum"Aircraft Fleet Addendum AttachedPage 2 of 5UW001 (01-16)Aircraft OperationsExcluding Passengers and Property DamageIncludingExcluding CrewAll Bodily Injury Limited toOther LiabilityPilotsPassenger Bodily Injury Limited to1990 Vaughn Road, Suite 350 Kennesaw, Georgia 30144 Has applicant or any of the applicant's pilots ever paid, or had paid on their behalf, any settlement for claims arising out of the Chemical Liability Hazard (chemical drift coverage) INSURANCE ?Chemical Liability CoverageEach PersonEach OccurenceAggregateBodily Injury Excluding Passengers, Excluding ChemicalBodily Injury Excluding Passengers.

8 Including Property Damage Excluding ChemicalProperty Damage Including Combined Single Limit Bodily Injury/Property Damage Excluding chemicalCombined Single Limit Bodily Injury/Property Damage Including chemical Comprehensive ChemicalLimited ChemicalComprehensive ChemicalLimited ChemicalComprehensive ChemicalLimited ChemicalWhat percentage of total application hours during the policy period involve:Herbicides:Fungicides:%Insectici desFertilizers:%%%Membership of any Other AssociationsAttended PAASSI ndustry of State Plant Board SeminarsTraining in the Use of ChemicalsRecurrent Training of PilotsYesNoAre you a member of the National Agricultural Aviation Association?

9 YesNoAre you a member of a State Aerial Aviation Association?Page 3 of 5UW001 (01-16)List states where aerial application will be made:Attach a completed Flying Roster as of policy inception which must include: Full Name, Age, Certification, Endorsements, Ratings(s), Total Hours Logged, Retractable Gear Hours, and Conventional Gear Hours (if applicable), Club Aircraft the pilot will operate, and is the pilot a club member or officer and officer position members all equal owners of the aircraft?Does the club have written by-laws?Does the club designate specific CFI's for instructions to members?

10 YesNoYesNoYesNoIf "Yes" attach a "Yes" identify on pilot Club Applicants OnlyUseAnnual HoursUseAnnual HoursUseAnnual HoursBusiness and PleasureOffshore/oil rigLoggingIndustrial Aid (Corporate)Law Enforcement/policeHeli-skiingAir AmbulanceIn-flight pick-up/deliverySightseeing/air toursAerial ApplicationForest service/BLMS eismic oil/gas explorationInstructionSearch and RescueFirefighting/sire supportRentalTraffic WatchMovies/cinematographyAir TaxiPipeline/powerline patrolAerial photographyExternal load/slung cargoElectronic news gatheringCrew training UtilizationHelicopter Applicants OnlyNoYesYesNoHas any such claim been made that is still unsettled?