A. NAME & ADDRESS OF APPLICANT
Name:
Street:
City, State:
Zip:
B. SERVICES TO BE INSURED
For each box you tick, the corresponding section below must be duly completed. You can disregard all other sections.
Important
This questionnaire is to be duly completed and signed by the insured. In the event insurance is effected, this questionnaire will form part of the policy and cover is subject to the original signed questionnaire being received by the Company within 30 days from inception.
Any changes during the policy period in the nature of the insured’s operations, which materially changes or alters in any way the information provided in this questionnaire, must immediately be advised to the Company, failing which, the validity of the policy may be affected.
Name
Position
Signature
(By typing your name, you are officially signing this form)
Date
C. MARINE TERMINAL OPERATOR
C.1. PLEASE ADVISE ANNUAL GROSS TURNOVER:
C.2. PLEASE INDICATE VOLUMES HANDLED:
C.3. PLEASE LIST 5 MOST IMPORTANT NON-CONTAINERISED CARGOES HANDLED AT THE TERMINAL:
C.4. PLEASE ADVISE WHETHER YOU TRADE UNDER CONTRACTS, STANDARD TRADING CONDITIONS OR PORT ACTS WHICH PROVIDE FOR LIMITED LIABILITY IN NEGLIGENCE:
PLEASE PROVIDE COPY
C.5. PLEASE ADVISE WHETHER YOU EMPLOY:
A) OWN LABOURERS:
B) LABOURERS FROM A PORT LABOUR POOL:
C) LABOURERS FROM AN EMPLOYMENT AGENCY:
PLEASE NOTE THAT YOUR POLICY DOES NOT COVER YOUR LIABILITY FOR PERSONAL INJURY TO EMPLOYEES, INCLUDING LABOURERS HIRED FROM A PORT LABOUR POOL OR EMPLOYMENT AGENCY
C.6. DO YOU OPERATE A WAREHOUSE?
IF YES, PLEASE COMPLETE SECTION E OF THIS QUESTIONNAIRE.
C.7. DO YOU WISH TO INSURE TERMINAL HANDLING EQUIPMENT:
IF YES, PLEASE COMPLETE THE EQUIPMENT QUESTIONNAIRE.
C.8. PLEASE PROVIDE DETAILS ON SECURITY ARRANGEMENTS:
-
ACCESS / EXIT CONTROL:
-
SECURITY GUARDS:
-
PERIMETER FENCES:
-
ALARMS:
-
CLOSE CIRCUIT TV:
-
OTHER:
C.9. PLEASE ATTACH FULL CLAIMS HISTORY OF PAID AND OUTSTANDING CLAIMS INCL. LEGAL FEES FOR THE PAST 5 YEARS. FIGURES MUST BE SHOWN NET OF DEDUCTIBLE AND MENTION APPLICABLE DEDUCTIBLE FOR EACH YEAR.
NON-MARINE TERMINAL OPERATORS
D.1. PLEASE ADVISE ANNUAL GROSS TURNOVER:
D.2. PLEASE ADVISE WHETHER YOU PROVIDE ANY OF THE FOLLOWING SERVICES:
Check each that apply.
D.3. PLEASE INDICATE VOLUMES HANDLED:
D.4. PLEASE LIST FIVE MOST IMPORTANT NON-CONTAINERISED CARGOES HANDLED AT THE TERMINAL/DEPOT:
D.5. PLEASE ADVISE WHETHER YOU TRADE UNDER CONTRACTS, STANDARD TRADING CONDITIONS OR PORT ACTS WHICH PROVIDE FOR LIMITED LIABILITY IN NEGLIGENCE:
Please provide copy.
D.6. PLEASE ADVISE WHETHER YOU EMPLOY:
PLEASE NOTE THAT YOUR POLICY DOES NOT COVER YOUR LIABILITY FOR PERSONAL INJURY TO EMPLOYEES, INCLUDING LABOURERS HIRED FROM A PORT LABOUR POOL OR EMPLOYMENT AGENCY.
D.7. DO YOU OPERATE A WAREHOUSE?
If yes, please complete the equipment questionnaire.
D.9. PLEASE PROVIDE DETAILS ON SECURITY ARRANGEMENTS:
D.10. PLEASE ATTACH FULL CLAIMS HISTORY OF PAID AND OUTSTANDING CLAIMS INCL. LEGAL FEES FOR THE PAST 5 YEARS. FIGURES MUST BE SHOWN NET OF DEDUCTIBLE AND MENTION APPLICABLE DEDUCTIBLE FOR EACH YEAR.
E. WAREHOUSE OPERATOR
E.1. PLEASE ADVISE ANNUAL GROSS RECEIPTS OUT OF WAREHOUSING:
E.2. PLEASE ADVISE ADDRESS OF EACH WAREHOUSE LOCATION:
E.3. PLEASE DESCRIBE PREMISES:
A. WHAT IS THE GROUND FLOOR AREA IN M² ?
B. HOW MANY STORIES?
C. TOTAL AREA OF PREMISES AVAILABLE FOR STORAGE?
D. ANY BASEMENT USED FOR STORAGE?
IF YES, IS IT CONNECTED WITH POLICE STATION AND/OR SECURITY SERVICE?
E. DO YOU EMPLOY WATCHMEN
(i) DURING WORKING HOURS?
(ii) 24/24 HRS AND 7/7 DAYS?
F. DO YOU HAVE CLOSED SECURITY?
G. PLEASE LIST ANY OTHER POSSIBLE KIND OF PREMISES PROTECTION:
E.5. PLEASE PROVIDE:
A. MAXIMUM VALUE IN THE WAREHOUSE AT ANY ONE TIME:
B. AVERAGE VALUE IN THE WAREHOUSE AT ANY ONE TIME:
E.6. PLEASE INDICATE WHICH OF THE FOLLOWING SERVICES YOU PROVIDE:
E.7. PLEASE INDICATE WHAT PERCENTAGE OF YOUR WAREHOUSING IS REPRESENTED BY THE FOLLOWING CARGOES:
E.8. PLEASE ADVISE UNDER WHICH CONTRACT TERMS YOU TRADE. PLEASE PROVIDE A COPY.
E.9. PLEASE ADVISE AS A PERCENTAGE OF YOUR ANNUAL GROSS RECEIPTS YOU SUB-CONTRACT:
E.10. WHEN YOU SUB-CONTRACT, PLEASE ADVISE:
A. WHETHER YOU CHECK THE SUB-CONTRACTOR’S INSURANCE ARRANGEMENTS PRIOR TO USING HIS SERVICES:
B. WHETHER YOU OBTAIN AN INSURANCE CERTIFICATE FROM THE SUB-CONTRACTOR:
E.11. PLEASE ATTACH FULL CLAIMS HISTORY OF PAID AND OUTSTANDING CLAIMS INCL. LEGAL FEES FOR THE PAST 5 YEARS. FIGURES MUST BE SHOWN NET OF DEDUCTIBLE AND MENTION APPLICABLE DEDUCTIBLE FOR EACH YEAR.
F. CUSTOM CLEARANCE
F.1. PLEASE ADVISE ANNUAL GROSS INCOME IN RESPECT OF CUSTOM CLEARANCE, EXCLUDING DUTIES AND TAXES PAID BY CUSTOMERS:
F.2. PLEASE ADVISE WHETHER YOUR COMPANY:
F.3. PLEASE INDICATE:
A) WHETHER YOUR COMPANY HAS A CUSTOMS BOND:
B) WHETHER YOU ARRANGE CUSTOM CLEARANCE, INCLUDING ISSUING T-FORMS, FOR TRANSPORT AND/OR STORAGE OF SPIRITS AND/OR CIGARETTES:
C) IF THE ANSWER UNDER B IS YES, PLEASE ADVISE WHICH SECURITY ARRANGEMENTS YOU MAKE:
D) WHETHER YOU HAVE A SPECIAL PROCEDURE IN PLACE FOR CHECKING THE RELIABILITY AND FINANCIAL STATUS OF YOUR CUSTOMERS:
IF YES, PLEASE SPECIFY:
F.4. PLEASE ATTACH FULL CLAIMS HISTORY OF PAID AND OUTSTANDING CLAIMS INCL. LEGAL FEES FOR THE PAST 5 YEARS. FIGURES MUST BE SHOWN NET OF DEDUCTIBLE AND MENTION APPLICABLE DEDUCTIBLE FOR EACH YEAR.
