SAMPLE FORMAT

INSTITUTION LETTERHEAD

DATE:
TO:	William Coombs c/o University of Miami RSMAS/Marine Department Marine Technology Group 4600 Rickenbacker Causeway Miami, FL 33149

RE:	Certification of Self-Insurance for Scientific Party Boarding UM Research Vessels

____________________(Institution’s Name) ____________________ certifies that
____________________(Individual’s Name) ____________________ is/are covered under
this institution’s self-insured worker’s compensation program while aboard the research vessel,
the R/V ___________________ . cruise number___________________.

Such program is extended to provide worker’s compensation coverage to the named individual(s)
for the duration of any scientific cruise aboard University of Miami research vessels.

(Please list additional individuals on the back of this certificate).

Signature: ___________________________
(Risk Manager or Plan Manager)