Issued in accordance with the provisions of article 12 of the Nairobi International Convention on the Removal of Wrecks, 2007
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 registered 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 Nairobi International Convention on the Removal of Wrecks, 2007.
Type of Security
Duration of Security
Name and address of the insurer(s) and/or guarantor(s)
This certificate is valid until
Issued or certified by the Government of
(Full designation of the State)
The following text should be used when a State Party avails itself of article 12, paragraph 3:
The present certificate is issued under the authority of the Government of (full designation of the State) by (name of institution or organization)
(Signature and Title of issuing or certifying official)
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 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.
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