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Form Application for Marine Surveyors

    MARINE SURVEYORS APPLICATION

    Company Name:

    Address:

    VAT No:

    Telephone:

    Fax:

    Insurance broker to whom quotation should be sent:

    1 General Information

    a. Date company established

    b. Names and addresses of any subsidiary, affiliated, associated companies or branch offices which you wish to include in the insurance:

    Name:

    Address:

    Street:

    City, Sate:

    Zip Code:

    Main Activity:

    Attatch file for extras:

    c. Number of Directors/Partners

    Total number of staff

    (including directors, surveyors and office staff engaged in providing services)

    d. Names, positions, professional qualifications and number of years experience of your surveyors, including working partners and directors (attatch file).

    e. Name of person to whom correspondence should be addressed:

    f. Are you a member of any trade association?

    (If “Yes” please detail)

    2 Income

    Please estimate you gross annual fees, and indicate currency, e.g. US$

    a. Last financial year

    b. Previous financial year

    c. Estimate for forthcoming year

    Please estimate against the services you provide the percentage of annual fees provided by each category of client:

    Percentage of annual fees

    Percentage of annual fees

    Hull underwriters

    Ship owners/charters or their P&I Club

    Cargo underwriters

    CMR (road transport) underwriters

    Non-marine underwriters

    Quality control, Superintendence ets

    Other

    If "Other" filled out, please provide breif explanation:

    Please advise gross fees paid to sub-contractors, and indicate currency, e.g. US$

    a. Last financial year

    b. Previous financial year

    c. Estimate for forthcoming year

    3 Principals

    Please name the principals for whom you regularly act

    Do you approve towage arrangements for ships, oil rigs, barges, offshore production
    facilities, or any other craft?

    If “Yes”, please indicate what percentage of your
    annual fees relates to towage approval works:

    4 Trading Conditions and documentation

    Do you use standard trading terms and conditions?

    (if “Yes” – please provide a copy)

    Do you have any contracts or agreements with specific clients?

    (if “Yes” – please advise the name(s) of these clients and provide a copy of the contract or agreement)

    5 Claims History

    a. Have any claims been made against you, or have there been any circumstances likely to give rise to a claim being made against you, in the last 5 years?

    If “Yes” please give details

    b. Has any insurer

    i. Declined to insure you?

    ii. Cancelled your insurance?

    iii. Refused to renew your insurance?

    iv. Imposed penalties or special terms?

    If “Yes” please give details:

    c. Are you currently insured against the risks covered by ITIC?

    If "Yes" with whom?:

    6 Limits and Deductibles

    Please indicate any preferred limits or deductibles

    Alternative 1

    Limit

    Deductible

    Please state currency

    Alternative 2

    Limit

    Deductible

    Please state currency

    7 Quality Assurance

    Have you obtained quality assurance accreditation in accordance with BS5750/ISO9002?

    8 Please supply any literature about your company which is relevant to this proposal.

    DECLARATION

    We declare that the information and answers given in this form are true to the best of our knowledge and belief and that we have not misstated or suppressed any material facts that might influence the Company’s assessment of the risk. We also understand that completion of this form does not bind the Company to accept this insurance but, if terms are agreed, it will form part of our contract with the Company.

    Signed

    (By typing your name, you are officially signing this form)

    Status of Signatory

    This proposal form must be completed and signed by a person who is authorised to bind the proposer.

    Copyright by Capacity Marine. All rights reserved.

    Copyright by Capacity Marine. All rights reserved.