The Offshore Pollution Liability Association Ltd

Form FR-2

VERIFICATION OF INSURANCE

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ISSUED TO The Offshore Pollution Liability Association Limited (hereinafter referred to as the
" Association"), whose address is. .........................................................................................................

We the undersigned Insurance Brokers hereby certify and agree:

(1)	that Policy Number .................................. effective from ................................................(Time and Date) and expiring ..................................................................... (Time and Date)     has been issued to ................................................................................................ (hereinafter referred to as the "Insured"), whose address is .................................................................................................................................. Limit: Per Incident US$ ............................... Aggregate Per Policy Year US$ ............................... Deductible: Per Incident US$ ............................ Policy applies to ........................................................... .......................................................................................... Description and location of Designated Licence(s)
(2)	that the policy covers the Insured's liability for claims for Remedial Measures and/or Pollution Damage arising out of or resulting from an Incident, as those terms are defined in the Offshore Pollution Liability Agreement dated 4th September 1974 as amended from time to time (hereinafter referred to as "OPOL"), occurring during the period the policy is in effect;
(3)	that the coverage afforded by the said policy will not be cancelled or materially changed until notice in writing has been given to the Insured and to the Association at
furthermore, that such cancellation and/or change shall not become effective until after the expiration of 30 days from the date the notice is received by the Association, or until substitute evidence of financial responsibility as required by OPOL has been filed with and accepted by the Association, whichever occurs first; and
(4)	that any amendment, change or extension of such contract will only be effected by specific endorsement attached to the policy.
The issuance of this document does not make the Association an additional insured, nor does it modify in any manner the contract of insurance between the Insured and the Insurers.

Date ........................................................... Name of Agent or Broker ............................................................

Address...................................................... By ............................................................. (Authorised Signature)

................................................................... Name .........................................................(Typed or Printed)

................................................................... Title ........................................................... (Typed or Printed)