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Application for Certificate of Financial Responsibility (Federal Maritime Commission)

This is a Federal Maritime Commission certificate of financial responsibility (United States). The form provided here is simply a sample of what the actual Form FMC-131 looks like.

Form FMC-131

FEDERAL MARITIME COMMISSION
Washington, DC 20573

Application for Certificate of Financial Responsibility

In compliance with the provisions of Pub. L. 89-777 and 46 CFR Part 540, application is hereby made for a Certificate of Financial Responsibility (check one or both as applicable):

[____] for indemnification of passengers for nonperformance;

[____] Initial application;

[____] Certificate has previously been applied for (if so, give date of application and action taken thereon).

[____] to meet liability incurred for death or injury to passengers or other persons;

[____] Initial application;

[____] Certificate has previously been applied for (if so, give date of application and action taken thereon).

Instructions

Submit two (2) typed copies of the application to the Secretary, Federal Maritime Commission, Washington, D.C. 20573. The application is in four parts: Part I -- General; Part II -- Performance; Part III -- Casualty and Part IV -- Declaration. Applicants must answer all questions in Part I and Part IV, then Parts II and/or Part III as appropriate. Instructions relating to Part II and Part III are contained at the beginning of the respective part. If the information required to be submitted under 46 CFR Part 540 has been previously submitted under other rules and regulations of the Commission, state when and for what reason such information was submitted. If previously submitted, it is not necessary to resubmit. If additional space is required, supplementary sheets may be attached.

Part I - General

Answer All Questions

1. (a) Legal business name: ____________________________

(b) English equivalent of legal name if customarily written in language other than English: ____________________________

(c) Trade name or names used: ____________________________

2. (a) State applicant's legal form of organization, i.e., whether operating as an individual, corporation, partnership, association, joint stock company, business trust, or other organized group of persons (whether incorporated or not), or as a receiver, trustee, or other liquidating agent, and describe current business activities and length of time engaged therein.

____________________________

(b) If a corporation, association, joint stock company, business trust, or other organization, give:

Name of State or country in which incorporated or organized. ____________________________

Date of the incorporation or organization. ____________________________

(c) If a partnership, give name and address of each partner: ____________________________

3. Give following information regarding any person or company controlling, controlled by, or under common control with you (answer only if applying as a self-insurer under Part II or Part III).

Name ____________________________

Address ____________________________

Business and relationship to you ____________________________

4. In relation to the passenger transportation engaged in by you to or from U.S. ports:

Do you own all the vessels? [____] Yes [____] No (If "No'' indicate the nature of the arrangements under which those not owned by you are available to you (e.g., bareboat, time, voyage, or other charter, or arrangement).

5. Name of each passenger vessel having accommodations for 50 or more passengers and embarking passengers at U.S. ports:

Name ____________________________

Country of registry ____________________________

Registration No. ____________________________

Maximum number of berth or stateroom accommodations ____________________________

6. Submit a copy of passenger ticket or other contract evidencing the sale of passenger transportation.

7. Name and address of applicant's U.S. agent or other person authorized to accept legal service in the United States.

Part II - Performance

Answer items 8 - 15 if applying for Certificate of Financial Responsibility for *The filing of sailing schedules will be acceptable in answers to this question.

Indemnification of Passengers for Nonperformance. If you are filing evidence of insurance, escrow account, guaranty or surety bond under Subpart A of 46 CFR Part 540 and providing at least fifteen (15) million dollars (U.S.) of coverage, you need not answer questions 10 - 15. 8. If you are providing at least fifteen (15) million dollars (U.S.) of coverage, state type of evidence and name and address of applicant's insurer, escrow agent, guarantor or surety (as appropriate).

9.* A Certificate (Performance) is desired for the following proposed passenger voyage or voyages: (Give itinerary and indicate whether the Certificate is for a single voyage, multiple voyages or all voyages scheduled annually.)

Vessel ____________________________

Voyage date ____________________________

Voyage itinerary ____________________________

10. Items 11 - 15 are optional methods; answer only the one item which is applicable to this application. Check the appropriate box below:

[____] Insurance (item 11).

[____] Escrow (item 12).

[____] Surety bond (item 13).

[____] Guaranty (item 14).

[____] Self-insurer (item 15).

11. (a) Total amount of performance insurance which is to be computed in accordance with 46 CFR 540.5. (Evidence of insurance must be filed with the Federal Maritime Commission before a Certificate (Performance) may be issued.)

(b) Method by which insurance amount is determined (attach data substantiating that amount is not less than that prescribed in 46 CFR 540.5).

(c) Name and address of applicant's insurer for performance policy.

12. (a) Name and address of applicant's escrow agent. (Applicant may pledge cash or U.S. Government securities, in lieu of a surety bond, to fulfill the indemnification provisions of Pub. L. 89-777.)

(b) Total escrow deposit which is to be computed in accordance with 46 CFR 540.5. (Escrow agreement must be filed with the Federal Maritime Commission before a Certificate (Performance) will be issued.)

Cash $____________________________.

U.S. Government Securities $____________________________.

(c) Method by which escrow amount is determined (attach data substantiating that amount is not less than that prescribed by 46 CFR 540.5).

13. (a) Total amount of surety bond in accordance with 46 CFR 540.6. (The bond must be filed with the Federal Maritime Commission before a Certificate (Performance) may be issued.)

(b) Method by which bond amount is determined (attach data substantiating that amount is not less than that prescribed in 46 CFR 540.6).

(c) Name and address of applicant's surety on performance bond.

14. (a) Total amount of guaranty which is to be computed in accordance with 46 CFR 540.5. (Guaranty must be filed with the Federal Maritime Commission before a Certificate (Performance) may be issued.)

(b) Method by which guaranty amount is determined (attach data substantiating that amount is not less than that prescribed in 46 CFR 540.5).

(c) Name and address of applicant's guarantor.

15. If applicant intends to qualify as a self-insurer for a Certificate (Performance) under 46 CFR 540.5, attach all data, statements, and documentation required therein.

Part III - Casualty

Answer Items 16 - 22 if Applying for Certificate of Financial Responsibility to Meet Liability Incurred for Death or Injury to Passengers or Other Persons 16. (a) Name of passenger vessel subject to section 2 of Pub. L. 89-777 operated by you to or from U.S. ports which has largest number of berth or stateroom accommodations.

(b) State the maximum number of berth or stateroom accommodations.

17. Amount of death or injury liability coverage based on number of accommodations aboard vessel named in item 16 above, calculated in accordance with 46 CFR 540.24. Items 18 - 22 Are Optional Methods: Answer Only the One Item Which is Applicable to This Application

18. (a) Total amount of applicant's insurance. (Evidence of the insurance must be filed with the Federal Maritime Commission before a Certificate (Casualty) will be issued.) (b) Name and address of applicant's insurer.

19. (a) Total amount of surety bond. (Bond must be filed with the Federal Maritime Commission before a Certificate (Casualty) will be issued.)

(b) Name and address of applicant's surety for death or injury bond.

20. (a) Total amount of escrow deposit. (Escrow agreement must be filed with the Federal Maritime Commission before a Certificate (Casualty) will be issued.)

(b) Name and address of applicant's escrow agent.

21. (a) Total amount of guaranty. (Guaranty must be filed with the Federal Maritime Commission before a Certificate (Casualty) will be issued.)

(b) Name and address of applicant's guarantor.

22. If applicant intends to qualify as a self-insurer for a Certificate (Casualty) under 46 CFR 540.24(c), attach all data, statements and documentation required therein.

Part IV - Declaration

This application is submitted by or on behalf of

(a) Name. ____________________________

(b) Name and title of official. ____________________________

(c) Home office -- Street and number. ____________________________

(d) City. ____________________________

(e) State or country. ____________________________

(f) ZIP Code. ____________________________

(g) Principal office in the United States -- Street and number. ____________________________

(h) City. ____________________________

(I) State. ____________________________

I declare that I have examined this application, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete.

By ____________________________ (Signature of official)

____________________________ (Date)

Comments: ____________________________

____________________________

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