THIS CERTIFICATEREQUIRES ENDORSEMENT IN
THE EVENT OF ASSIGNMENT

Certificate of Insurance No.
This is to Certify that a Contract in favour of (insert ASSURED NAME), underwritten by certain Underwriters at Lloyd’s
has been effected by (insert BROKER NAME) acting on behalf of (insert ASSURED NAME), for insurances attaching thereto during theperiod commencing the (insert DAY number) day of (insert MONTH) 20 (insert YEAR), and ending the (insert DAY number) day of (insertMONTH) 20 (insert YEAR), both days inclusive, and that the said Underwriters at Lloyd’s have undertaken to issue Policy/Policies ofInsurance to cover, up to (insert POLICY LIMIT), in all by any one approved (insert MODES OF TRANSPORT), (insert CARGODESCRIPTION COVERED BY THE POLICY), from any port or ports, place or places in (insert GEOGRAPHICAL AREAS COVERED BYTHE POLICY), to any port or ports, place or places in (insert GEOGRAPHICAL AREAS COVERED BY THE POLICY), and that (insertASSURED NAME), are entitled to declare against the said Contract insurances attaching thereto.

INSURED VALUE/Currency(Insert SIGNATURE)
Conveyance

FromVia/ToTo(Insert COMPANY NAME)
Dated at (Insert LOCATION and DATE)

Marks and Numbers

Interest

We hereby declare for Insurance under the said Contract interest as specified above so valued subject to the special conditions stated below and on the back hereof.
(Insert KEY POLICY TERMS AND CONDITIONS AND REFERENCE ANY POLICY DEDUCTIBLE(S))

Underwriters agree losses, if any, shall be payable to the order ofon surrender of this Certificate.

IMPORTANT INSTRUCTIONS IN EVENT OF CLAIM
TO THE CLAIMANT: In the event of physical evidence of loss or damage which may result in a claim under this insurance immediate notice must be given to the Lloyd’s Agent at
the port or place where the loss or damage is discovered in order that they may examine the goods and issue a survey report if required. A full list of Lloyd’s Agents can be foundat http://www.lloyds.com/lloydsagencydirectory
TO THE LLOYD’S AGENT: As per Lloyd’s Agency standard terms of engagement immediate notice of the potential claim is to be given to (insert CLAIMS CONTACT INFORMATION)
PLEASE SEE FURTHER IMPORTANT INSTRUCTIONS ON REVERSE

Dated
This Certificate not valid unless the Declaration be signed by(insert ASSURED NAME)

SignedAuthorised Signatory

Classification: Confidential

IMPORTANT INSTRUCTIONS IN EVENT OF CLAIM
DOCUMENTATION OF CLAIMSTo enable claims to be dealt with promptly, the Assured or their Agents areadvised to submit all available supporting documents without delay, including
when applicable:1. Original policy or certificate of insurance.
2. Original or copy shipping invoices, together with shipping specification
and/or weight notes.
3. Original Bill of Lading and/or other contract of carriage.
4. Survey report or other documentary evidence to show the extent of theloss or damage.
5. Landing account and weight notes at final destination.
6. Correspondence exchanged with the Carriers and other parties regarding
their liability for the loss or damage.

IMPORTANTLIABILITY OF CARRIERS, BAILEES OR OTHER THIRD PARTIES
It is the duty of the Assured and their Agents, in all cases, to take such measures
as may be reasonable for the purpose of averting or minimising a loss and to ensurethat all rights against Carriers, Bailees or other third parties are properly preserved
and exercised. In particular, the Assured or their Agents are required:1. To claim immediately on the Carriers, Port Authorities or other Bailees for any
missing packages.
2. In no circumstances, except under written protest, to give clean receipts wheregoods are in doubtful condition.
3. When delivery is made by Container, to ensure that the Container and its
seals are examined immediately by their responsible official. If the Container
is delivered damaged or with seals broken or missing or with seals other thanas stated in the shipping documents, to clause the delivery receipt accordingly
and retain all defective or irregular seals for subsequent identification.
4. To apply immediately for survey by Carriers' or other Bailees' Representatives
if any loss or damage be apparent and claim on the Carriers or other Bailees
for any actual loss or damage found at such survey.
5. To give notice in writing to the Carriers or other Bailees within 3 days of delivery
if the loss or damage was not apparent at the time of taking delivery.
Note.- The Consignees or their Agents are recommended to make themselves familiar
with the Regulations of the Port Authorities at the port of discharge.

NOTE:-The Institute Clauses incorporated herein are deemed to be those current at the time of commencement of the risk.
It is necessary for the Assured when they become aware of an event which is "held covered" under this Insurance to give prompt noticeto Underwriters and the right to such cover is dependent upon compliance with this obligation.
Lloyd's Agents referred to herein are not insurers and are not liable for claims arising on this Certificate. The service of legal proceedings
upon Lloyd's Agents is not effective service for the purpose of starting legal proceedings against Underwriters.

(Insert COMPANY NAME) is authorised under the Financial Services and Markets Act 2000 and regulated by the Financial Conduct Authority and Prudential Regulation Authority.

Classification: Confidential