Appendix B4-I
Clasification Society 2024 - Version 9.40
Statutory Documents - ILO Conventions - International Labour Conference – Maritime Labour Convention, 2006 - The Regulations and the Code - Title 5 – Compliance and enforcement - Appendix B4-I

Appendix B4-I

Model Receipt and Release Form

referred to in Guideline B4.2.2

Ship (name, port of registry and IMO number):...................................................

Incident (date and place):..........................................................................................

Seafarer/legal heir and/or dependant: ....................................................................

Shipowner:...................................................................................................................

I, [Seafarer] [Seafarer’s legal heir and/or dependant]* hereby acknowledge receipt of the sum of [currency and amount] in satisfaction of the Shipowner’s obligation to pay contractual compensation for personal injury and/or death under the terms and conditions of [my] [the Seafarer’s]* employment and I hereby release the Shipowner from their obligations under the said terms and conditions.

The payment is made without admission of liability of any claims and is accepted without prejudice to [my] [the Seafarer’s legal heir and/or dependant’s]* right to pursue any claim at law in respect of negligence, tort, breach of statutory duty or any other legal redress available and arising out of the above incident.

Dated:...........................................................................................................................

Seafarer/legal heir and/or dependant: ....................................................................

Signed:..........................................................................................................................

For acknowledgement:

Shipowner/Shipowner representative:

Signed:..........................................................................................................................

Financial security provider:

Signed:..........................................................................................................................

___________

* Delete as appropriate.

Parent topic: Title 5 – Compliance and enforcement
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