ࡱ> /9.5@  +bjbj22 KXX"-nnnFFF8~ <-(J ####W$()-$l.R0M-n"M-qb-!!!|8n#!#!!"#Vn@# `,iF 0#d#Dx-0-8#r1!r1@#r1n@#$vT!D'xM-M-F!(F MARINE COMMERCIAL LIABILITY SUPPLEMENTARY INFORMATION FOR VESSEL CONSTRUCTION Name of Applicant______________________________________________________________________ Address ______________________________________________________________________________ ______________________________________________________________________________ If accepted by the Company, coverage is desired beginning_________________, 19____. 1. Location of yard(s) (a)______________________________ (c)_____________________________ ______________________________ _____________________________ (b)______________________________ (d)_____________________________ ______________________________ _____________________________ 2. Type of vessels built M A T E R I A L S (Check) Vessel No. Built Steel Wood Alum. Fiberglass Other Annually ______________________________________________________________________________ Deck Barges Crane Barges Tank Barges Hopper Barges Towboats Crewboats Supply Boats Fishing Vessels Private/Pleasure (Type) Other 3. Describe method of launch________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Describe extent of trials (hours of trial operation, number of crew, usual number of others aboard) ______________________________________________________________________________ ______________________________________________________________________________ Describe delivery trips (distance, number of crew, others aboard, tower or land conveyance) ______________________________________________________________________________ ______________________________________________________________________________ 4. Usual Construction Period (months) Average Contract Value Maximum Contract Value Deck Barges ______________ $___________________ $____________________ Crane Barges ______________ $___________________ $____________________ Tank Barges ______________ $___________________ $____________________ Hopper Barges ______________ $___________________ $____________________ Towboats ______________ $___________________ $____________________ Crewboats ______________ $___________________ $____________________ Supply Boats ______________ $___________________ $____________________ Fishing Vessels ______________ $___________________ $____________________ Private/Pleasure ______________ $___________________ $____________________ Other ______________ $___________________ $____________________ Maximum contract values at any one yard location _____________________________________ 5. IF APPLICATION IS FOR COVERAGE ON ONE SPECIFIC VESSEL, complete this item: (a) Type of vessel____________________________________________________________ (b) Dimensions ____________________________________________________________ (c) Hull Materials____________________________________________________________ (d) Completed Contract Price $_____________________________________________ (e) Period of Construction: From______________, 19___ to_______________, 19__ (f) See item 1 above - construction site (check) (a) ( ) (b) ( ) (c) ( ) (d) ( ) (g) Describe extent of trials_____________________________________________________ ________________________________________________________________________ (h) Delivery description and location______________________________________________ _________________________________________________________________________ 6. Fire Protection: (a) Public fire department Paid ( ) Volunteer ( ) (b) Distance to nearest fire department_______________________________________________ (c) Public fire hydrants: How many?__________How far distant?________________ (d) Public fire mains: Size________________Pressure_______________________ (e) Private fire protection (describe)_________________________________________________ ___________________________________________________________________________ (f) Building fire protection (describe)________________________________________________ ___________________________________________________________________________ 7. Watchmen: How many employed?_____________________How many on each shift?__________________ Watchclocks? Yes ( ) No ( ) Is yard fenced? Yes ( ) No ( ) Is guard at gate when operating? Yes ( ) No ( ) 8. Describe applicants experience as builder____________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 9. Applicants gross receipts for past 5 years derived from vessel construction: $________________________19____ $________________________19____ $________________________19____ $________________________19____ $________________________19____ Percentage of repair work sub-contracted __________. Is sub-contracted work accompanied by a hold harmless/indemnity agreement? __________ Waiver of subrogation? __________ Are certificates of insurance required? __________ What limits? __________________ Does the applicant enter into contractual agreements other than those normal to the industry? _______. If so, provide details and copies of contracts: Current insurance carrier: Current premiums (i.e. Minimum & Deposit and adjustment rate): Limit of liability and deductible requested: Has any policy or coverage been declined or non-renewed during the past five years?__________ If so, provide details: Are revenues generated from other than the marine operations described above? _____________ If so, provide details: Does applicant use employee leasing services and/or temporary workers? __________ If so, are there hold harmless/indemnity agreements in place in the applicants favor? __________ Waiver of subrogation? __________ Are certificates of insurance obtained? __________ What limits?_______________________ 18. Contact and phone number to arrange an inspection: 19. LOSS EXPERIENCE (past 5 years) including any insured losses. Show all losses gross (before application of deductible, if any): Date of Loss Description Amount (Gross) ___________________ ________________________________ ____________________ ___________________ ________________________________ ____________________ ___________________ ________________________________ ____________________ ___________________ ________________________________ ____________________ ___________________ ________________________________ ____________________ ___________________ ________________________________ ____________________ ___________________ ________________________________ ____________________ 20. Are vessels under construction financed?__________If yes, with whom____________________ ___________________________________________Current line of credit $________________ 21. REMARKS (Please use this space to comment upon facts not brought out in answering application items above - i.e. Emergency procedure, Loss Control, OSHA compliance, plans for expansion or upgrading of facilities, etc.) ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime. (Applicable to New York State Only.) Signing this application does not bind the Applicant to purchase the insurance or the Company to accept the risk, but it is agreed that this application shall be the basis of the contract should a policy be issued. _________________________________ _________________________________ ____________________________ Applicant Signature Company Title Date _________________________________ _________________________________ ____________________________ Producer Signature Company Title Date Ed. 7/99 Page  PAGE 4 of  NUMPAGES 4  EMBED Word.Picture.8     & ' ; < S T n o G\ !$!&!1!4!B!((***************+++ + +ɾɾݶ᫶jv5C hfUVjhfUhfhmHnHujh/fUh h/fh h/f>*h/fhf h/fCJ h/f5jhf5UmHnHu:!"TUV U V W O P  $a$$a$$a$gdf** + * ]  & ; S n H NM<\7!"pq^-XQF<9FGm de=>*+X Y !!C!!!$"^ & F$"o""#P#Q#R#S##$$$$$$9%%%)&y&&'i'j'k'l'm'n'o'p'p'q'r's't'(())*1*2****** + + + +gdf 00]0^0/ =!"#$%`! 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