OMB No. 3072-0018

Expires 11/30/2026

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 (bcl@fmc.gov) 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 (bcl@fmc.gov), 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)