Important Note:
WHEN FILLING OUT THIS APPLICATION, ALL QUESTIONS MUST BE ANSWERED COMPLETELY, IF A QUESTION IS NOT APPLICABLE TO THE OPERATIONS OF THE COMPANY, PLEASE ANSWER “NOT APPLICABLE” OR “N/A”. IF THE ANSWER IS NONE, STATE “NONE”. IF MORE SPACE IS REQUIRED TO COMPLETELY ANSWER A QUESTION, PLEASE ATTACH A SEPARATE SHEET OF PAPER AND IDENTIFY THE QUESTION IT RESPONDS TO. LEAVE NO SPACE BLANK.
Name of Applicant:
Full address (including zip code):
Contact Name and telephone number (for survey purposes):
Name:
Telephone Number:
Location of Yard(s):
Address:
Fire Protection
Public Fire Department:
Private Fire Protection (describe in full):
Watchman Service:
How many?
Is service provided 24 Hours per day
Watch Clock
Is yard fenced?
Guard at gate?
Describe Property Adjacent to the Yard:
Policy Period:
From:
To:
Limit of liability required: Any one occurrence $:
Gross receipts for past 3 years:
Breakdown of repairs by the following types of work:
Hull repairs %:
Machinery %:
Hydraulics %:
Welding %:
Electrical %:
Gas freeing %:
Boiler %:
Painting %:
Other %:
Gas Freeing Operations
a) If gas freeing operations are carried out, state number of vessels gas freed last year:
b) Does the applicant employ a full-time gas free chemist:
Does the applicant employ an outside sub-contracted chemist:
c) Does the applicant strictly adhere to the rules & regulations of the national fire protection agency applicable to work on vessels which have carried combustible liquid in bulk, as fuel or cargo.
If "No", please explain:
Employees
How many employees does the applicant have:
Jones Act:
What is the gross wageroll:
USLHWA:
Yard Facilities:
Drydocks
Marine Railways
Repair Piers
Travel Lifts or Hoists
Type of vessels worked on:
US Navy %:
Marad %:
Pleasure Craft %:
Commercial "Blue Water" %:
Commercial "Brown Water" %:
Other %:
If "other", please specify:
Do you require Dept. of Defense End.?
Give details of any contractual liability limitation agreements and attach copy of repair contract:
Repairs
Number of vessels in repair yard last year:
Number of vessels repaired outside the yard last year:
Average value of vessel:
Maximum value of vessel:
Other work (work other than ship repair):
Gross receipts:
Give full details:
"Downstream" operations:
What is the percentage of work carried out away from the applicant’s premises where the vessel, craft, or equipment being worked on may be considered in somebody else’s custody and control?
What is the nature of this "Downstream" work?
Where is the work carried out?
Give details of owned, hired or leased watercraft, docks or floats used during repair operations:
Insurance:
Has any insurance company ever cancelled or declined to issue or renew this form of insurance for this applicant?
Present insurance company:
Loss History:
List all claims/occurrences made against you during the past five (5) years resulting from operations covered by this form of policy. If “none”, state “none”.
PLEASE ATTACH YOUR AUDITED FINANCIAL STATEMENT. FAILURE TO PROVIDE AN AUDITED FINANCIAL STATEMENT MAY RESULT IN A PREMIUM SURCHARGE.
Audited Financial Statement:
Please attach any additional documentation here
Additional documentation 1:
Additional documentation 2:
Additional documentation 3:
Additional documentation 4:
Additional documentation 4:
Additional documentation 4:
SIGNING THIS APPLICATION DOES NOT BIND THE APPLICANT NOR THE INSURER TO THE INSURANCE, BUT IT IS AGREED THAT THE STATEMENTS CONTAINED IN THIS APPLICATION SHALL FORM THE BASIS ON WHICH THIS POLICY IS ISSUED, AND THE APPLICANT WARRANTS ALL SUCH STATEMENTS TO BE TRUE TO THE BEST OF ITS KNOWLEDGE AND BELIEF.
Producer's Signature:
Date:
Applicant's Signature:
Date:
(By typing your name, you are officially signing this form)
