DECLARATION BY BROKER (FORM 5)

[LETTERHEAD OF BROKER]

DECLARATION OF INSURANCE

CIVIL AVIATION (CARRIERS’ LIABILITY) ACT 1959 - AUSTRALIA

(INTERNATIONAL CARRIER)

AIR CARRIER:			XXX (the “Carrier”)

INSURANCE BROKER:	XXX (the “Broker”)

In this declaration, “personal injury liability”, in relation to the Carrier, means liability in respect of the death of, or bodily injury, sickness, disease, fright, shock or mental anguish suffered by, passengers carried by air by the Carrier.

The Broker declares that:

1.	certain insurers (the “Insurers”) have issued policies of insurance to the Carrier covering the risks of personal injury liability;

2.	the policies of insurance became, or will become, effective from [date] and will expire on [date[;

3.	the Carrier’s right of indemnity under the policies of insurance for personal injury liability;

(a)	is for an amount of not less than 260,000 Special Drawing Rights per passenger;

(b)	is not affected by any breach of a safety-related requirement imposed by or under any Australian Act of Parliament or by the Australian Civil Aviation Authority;

(c)	is not contingent upon the financial condition or solvency of the Carrier or upon the Carrier not being or not becoming bankrupt or not beginning to be or not being wound up; and

(d) 	extends to liabilities arising from the operation of any aircraft by the Carrier in commercial air service;

4.	each of the Insurers is either:

(a)	authorised under section 23 or 24 of the Commonwealth of Australia’s Insurance Act 1973 to conduct insurance business in Australia; or

(b)	permitted or authorised to carry on insurance business under the law of a country other than Australia, not being a country identified in a notice published under Regulation 8 of the Commonwealth of Australia’s Civil Aviation (Carriers’ Liability) Regulations; and

5. 	         the Broker is issuing this declaration on behalf of the Insurers;

6. 	Personal injury liability coverage extended by the Policy(ies) is not subject to, or limited by, an AVN 2000 exclusion clause nor any other form of exclusion which may limit the insurer's indemnification of the insured in respect of liabilities arising from date recognition based, computer errors or failures.
			                                       [OR]

The Policy(ies) indemnify the insured for 'personal injury liability', as required by the Civil Aviation (Carriers' Liability) Act 1959 (including that Act as it has effect in a State of Australia), under the AVN57A (Australia) endorsement.

Signed for and on behalf of
[name of broker] by
[name and position of signatory]

DATE:   XXX