附件6

残骸清除责任保险证明（建议样本）

（国际航行船舶）

致：XX海事局

To: XX Maritime Safety Administration of the People’s Republic of China

船名：Name of Vessel:

船舶编号或呼号：Signal Letters:

IMO船舶识别号：IMO No:

总吨：Gross Tonnage:

船籍港：Port of Registry:

船舶种类：Type of Vessel:

航行区域： Trading Area:

登记船舶所有人名称及主要营业地址：

Name and Address of Ship Owner:

保险单号：

Policy No.：

兹证明上述具名船舶具有符合《2007年内罗毕国际船舶残骸清除公约》第十二条要求的下列保险或其他财务保证证明。

This is to certify that the above-named vessel is covered by the following insurance or other financial security in compliance with the requirements of Article 12 of the Nairobi International Convention on the Removal of Wrecks, 2007.

保险类别：Coverage:

保险期限： (北京时间/(格林威治时间 年 月 日 时

至 (北京时间/(格林威治时间 年 月 日 时

Period of insurance:From ____ (Beijing Time/GMT) to ____ (Beijing Time/GMT)

本保险人/担保人在提前3个月通知贵局的前提下，有权取消此证明，本保险人/担保人的责任自上述通知期限届满时自动终止，之后发生的事故，本保险人/担保人将不承担赔偿责任。

Provided always that the Insurer may cancel this Certificate by giving three months written notice to the above mentioned MSA whereupon the liability of the Insurer hereunder shall cease as from the date of expiry of the said period of notice but only as regards incidents arising thereafter.

本保险人/担保人名称：

Name of the Insurer(s) / Guarantor(s):

保险人/担保人地址：

Address of the Insurer(s) / Guarantor(s):

邮编：

P.C：

签发日期（盖章）：

DATE：