497 



ANNEX 



Certificate of Insurance or Other Financial Security in 

 Respect of Civil Liability for Oil Pollution Damage 



(Issued in Accordance with the Provisions of Article III of the 

 International Convention on Civil Liability for Oil Pollution 

 Damage, 1969) 



Name of ship 



Distinctive number or letters 



Port of registry. 



Name and address of 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 III of the International Convention on Civil 

 Liabihty for Oil Pollution Damage, 1969. 



Type of Becurity 



Duration of Security 



Name and Address of the Insurer{a) andjor Guarantor(s) 



Name 



Address 



This certificate is valid until 



Issued or certified by the Government of 



( Full deslicnation of the 8tatp) 

 At On 



(Place) (Date) 



(Sipnuture and title of issuing or ci-rtifyiiijt otUciul) 



explanatory notes 



1. If desired, the designation of the State may include a referenre 

 to the com|>etent public authority of the country where the certificate 

 is issued. 



2. If the total amount of security has been furni.shed by more than 

 one source, the amount of each of them should be indicated. 



3. If se<'urity is furnished in several forms, these should he enu- 

 merated. 



4. The entry "Duration of the Security" must stipulate the dat« on 

 which such security takes effect. 



