FMC-67 Ocean Transportation Intermediary Insurance Form Furnish

OMB No. 3072-0018
Expires 12/31/2023

Form FMC-67
FEDERAL MARITIME COMMISSION
Ocean Transportation Intermediary (OTI) Insurance Form
Form Furnished as Evidence of Financial Responsibility
Under 46 U.S.C. 40901-40904
This is to certify, that the (Name of Insurance Company), (hereinafter “Insurer”) of (Home Office
Address of Company) has issued to (OTI or Group or Association of OTIs [indicate whether
NVOCC(s) or Freight Forwarder(s)]) (hereinafter “Insured”) of (Address of OTI or Group or
Association of OTIs) a policy or policies of insurance for purposes of complying with the
provisions of Section 19 of the Shipping Act of 1984 (46 U.S.C. 40901-40904) and the rules and
regulations, as amended, of the Federal Maritime Commission, which provide compensation for
damages, reparations or penalties arising from the transportation-related activities of Insured, and
made pursuant to the Shipping Act of 1984 (46 U.S.C. 40101-41309) (Shipping Act).
Whereas, the Insured is or may become an OTI subject to the Shipping Act and the rules and
regulations of the Federal Maritime Commission, or is or may become a group or association of
OTIs, and desires to establish financial responsibility in accordance with section 19 of the Shipping
Act (46 U.S.C. 40901-40904), files with the Commission this Insurance Form as evidence of its
financial responsibility and evidence of a financial rating for the Insurer of Class V or higher under
the Financial Size Categories of A.M. Best & Company or equivalent from an acceptable
international rating organization on such organization's letterhead or designated form, or, in the
case of insurance provided by Underwriters at Lloyd's, documentation verifying membership in
Lloyd's, or, in the case of surplus lines insurers, documentation verifying inclusion on a current
“white list” issued by the Non-Admitted Insurers' Information Office of the National Association
of Insurance Commissioners.
Whereas, the Insurance is written to assure compliance by the Insured with section 19 of the
Shipping Act (46 U.S.C. 40901-40904), and the rules and regulations of the Federal Maritime
Commission relating to evidence of financial responsibility for OTIs, this Insurance shall be
available to pay any judgment obtained or any settlement made pursuant to a claim under 46 CFR
515.23 for damages against the Insured arising from the Insured's transportation-related activities
under the Shipping Act, or order for reparations issued pursuant to section 11 of the Shipping Act
(46 U.S.C. 41301-41302, 41305-41307(a)), or any penalty assessed against the Insured pursuant
to section 13 of the Shipping Act (46 U.S.C. 41107-41109).
Whereas, the Insurer certifies that it has sufficient and acceptable assets located in the United
States to cover all liabilities of Insured herein described, this Insurance shall inure to the benefit
of any and all persons who have a bona fide claim against the Insured pursuant to 46 CFR 515.23
arising from its transportation-related activities under the Shipping Act, or order of reparation
issued pursuant to section 11 of the Shipping Act (46 U.S.C. 41301-41302, 41305-41307(a)), and

to the benefit of the Federal Maritime Commission for any penalty assessed against the Insured
pursuant to section 13 of the Shipping Act (46 U.S.C. 41107-41109).
The Insurer consents to be sued directly in respect of any bona fide claim owed by Insured for
damages, reparations or penalties arising from the transportation-related activities under the
Shipping Act, of Insured in the event that such legal liability has not been discharged by the Insured
or Insurer after a claimant has obtained a final judgment (after appeal, if any) against the Insured
from a United States Federal or State Court of competent jurisdiction and has complied with the
procedures for collecting on such a judgment pursuant to 46 CFR 515.23, the Federal Maritime
Commission, or where all parties and claimants otherwise mutually consent, from a foreign court,
or where such claimant has become entitled to payment of a specified sum by virtue of a
compromise settlement agreement made with the Insured and/or Insurer pursuant to 46 CFR
515.23, whereby, upon payment of the agreed sum, the Insurer is to be fully, irrevocably and
unconditionally discharged from all further liability to such claimant; provided, however, that
Insurer's total obligation hereunder shall not exceed the amount per OTI set forth in 46 CFR 515.21
or the amount per group or association of OTIs set forth in 46 CFR 515.21.
The liability of the Insurer shall not be discharged by any payment or succession of payments
hereunder, unless and until such payment or payments shall aggregate the penalty of the Insurance
in the amount per member OTI set forth in 46 CFR 515.21, or the amount per group or association
of OTIs set forth in 46 CFR 515.21, regardless of the financial responsibility or lack thereof, or
the solvency or bankruptcy, of Insured.
The insurance evidenced by this undertaking shall be applicable only in relation to incidents
occurring on or after the effective date and before the date termination of this undertaking becomes
effective. The effective date of this undertaking shall be ___ day of __________, _____, and shall
continue in effect until discharged or terminated as herein provided. The Insured or the Insurer
may at any time terminate the Insurance by mail or email ([email protected]) written notice to the
Director, Bureau of Certification and Licensing, Federal Maritime Commission, Washington, DC.
20573. Such termination shall become effective thirty (30) days after receipt of said notice by the
Commission. The Insurer shall not be liable for any transportation-related activities under the
Shipping Act of the Insured after the expiration of the 30-day period but such termination shall not
affect the liability of the Insured and Insurer for such activities occurring prior to the date when
said termination becomes effective.
(Name of Agent) __________ domiciled in the United States, with offices located in the United
States, at __________ is hereby designated as the Insurer's agent for service of process for the
purposes of enforcing the Insurance certified to herein.
If more than one insurer joins in executing this document, that action constitutes joint and several
liability on the part of the insurers.
The Insurer will promptly notify the Director, Bureau of Certification and Licensing, Federal
Maritime Commission, Washington, DC. 20573, in writing by mail or email ([email protected]), of
all claims made, lawsuits filed, judgments rendered, and payments made against the Insurance.
Signed and sealed this _____ day of __________, _____.

___________________________________________________
Signature of Official signing on behalf of Insurer
___________________________________________________
Type Name and Title of signer

This Insurance Form has been filed with the Federal Maritime Commission.

Form FMC-67
(Rev. 12/2015)