Hong Kong Regulations

MERCHANT SHIPPING (LOCAL VESSELS) (COMPULSORY THIRD PARTY RISKS INSURANCE) REGULATION - SCHEDULE SCHEDULE

[sections 13 & 23]

CERTIFICATE OF INSURANCE

(Issued pursuant to section 13 of the Merchant Shipping (Local Vessels)
(Compulsory Third Party Risks Insurance) Regulation ( Cap 548 sub. leg. H))

Certificate No.: ........................... Policy No.:
.........................

Issued on: .........................

1. Name of policy holder(s)
...........................................................................

2. Class and type of local vessel
.....................................................................

Name of local vessel (if any)
......................................................................

Certificate of ownership number or description of local vessel
.......................

...........................................................................
.......................................

3. Period of Insurance from ............................... to
......................................

4. Amount of liability insured
........................................................................

5. Name of authorized insurer
.......................................................................

6. Persons or classes of persons entitled to have charge of the local vessel

...........................................................................
.........................................

7. The circumstances in which that person (or persons) will be indemnified

...........................................................................
.........................................

I hereby certify the above particulars in respect of a policy of insurance
issued by me.

And I further certify that the policy is issued in accordance with the
provisions of the Merchant Shipping (Local Vessels) (Compulsory Third Party
Risks Insurance) Regulation ( Cap 548 sub. leg. H).

....................................................... Authorized Insurer

Date: ..................................