Issued in accordance with the provisions of Article 12 of the International Convention on Liability and Compensation for Damage in Connection with the Carriage of Hazardous and Noxious Substances by Sea, 1996
Name of ship
|
Distinctive number or letters
|
IMO ship identification number
|
Port of registry
|
Name and full address of the principal place of business of the owner
|
|
|
|
|
|
This is to certify that there is in force in respect of the above-named ship a policy of insurance or other financial security satisfying the requirements of Article 12 of the International Convention on Liability and Compensation for Damage in Connection with the Carriage of Hazardous and Noxious Substances by Sea, 1996.
Type of security .....................................................................................
.................................................................................................................
Duration of security ..............................................................................
.................................................................................................................
Name and address of the insurer(s) and/or guarantor(s)
Name ......................................................................................................
Address ..................................................................................................
.................................................................................................................
This certificate is valid until .............................................................
Issued or certified by the Government of ........................................
.................................................................................................................
(Full designation of the State)
.................................................................................................................
(Signature and Title of issuing or certifying official)
Explanatory Notes:
1.If desired, the designation of the State may include a reference to the competent public authority of the country where the certificate is issued.
2.If the total amount of security has been furnished by more than one source, the amount of each of them should be indicated.
3.If security is furnished in several forms, these should be enumerated.
4.The entry “Duration of the Security” must stipulate the date on which such security takes effect.
5.The entry “Address” of the insurer(s) and/or guarantor(s) must indicate the principal place of business of the insurer(s) and/or guarantor(s). If appropriate, the place of business where the insurance or other security is established shall be indicated.