To the Owners, Managers, Agents and Master of the __________________

Dear Sirs,

In consideration of your agreement that I may board the above vessel for the purposes of,
inter alia, visitation and/or inspection from the time and place of embarkation and to the time
and place of disembarkation entered below, I, __________________________ hereby agree
as follows:

1. That I accept all risks of whatsoever nature and howsoever arising, expressly including
risks which may result from you, your servants’ or agents’ negligence or any defects in
the vessel, during the period that I am aboard the vessel, including, but not limited
to illness, injury, death, loss of or damage to my property and personal effects, and
further expressly accept responsibility for any and all costs, charges or expenses which
may arise whether directly or indirectly in consequence of such matters.

2. That I shall hold your harmless and indemnify you, and each of you, in respect of any
losses, damages, claims, liabilities, fines, costs, charges or expenses whether medical
or otherwise, including those associated with any deviation of the vessel or any need to
repatriate me from the vessel, which you may suffer or incur whether directly or
indirectly in consequence of or in connection with my being aboard the vessel and
whether or not such may arise in consequence of any negligent act or omission on
my part or on the part of you, your servants or agents or any defects in the vessel.

3. That should the vessel for any reason whatsoever not be able to return me to the
place of disembarkation entered below it is understood that I must provide myself
with a passage home or elsewhere and that you shall be under no responsibility
whatsoever in consequence of such matters.

4. That I expressly undertake and agree on behalf of myself, my heirs, executors and
assignees to make no claim of any nature whatsoever, including but not limited to
claims in respect of illness, injury, death, loss of or damage to my property and
personal effects, against the Vessel, its Owners, operators, managers and their
servants or agents, whether or not such claim be occasioned by negligence, act,
omission or default by any one or more of the said parties.

5. That I undertake to indemnify Owners and all of the above mentioned parties against
any claims whatsoever, liabilities, loss, damage, costs and/or expenses which Owners,
their successors, heirs, servants or agents may incur, suffer or be put to arising out of
any act, negligence, omission or default by the undersigned.

6. Further I undertake to respect, obey and follow any relevant laws, regulations and
Master’s and crew’s instructions whilst on-board.

7. I confirm that I / my employers (delete as applicable) have arranged appropriate

insurance to cover my own medical costs, baggage and personal liabilities for the
voyage.

8. That I shall and in any event be properly deemed to be taken out adequate
personal insurance cover with a reputable insurance company to cover the
personal risks and liabilities assumed by me under this agreement.

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 9. Family members or friends accompanying seafarers on a voyage, not engaged in paid
work nor part of the routine working of the ship, are not considered seafarers under the
Maritime Labour Convention (MLC), nor under STCW or similar.

This indemnity shall be governed by and construed in accordance with English law and any
dispute deriving from this Indemnity shall be submitted to the exclusive jurisdiction of the
English Courts.

Witness: _____________________

Signature : _____________________

Date : _____________________

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