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.
