Form Application for Marine General Liability


MARINE GENERAL LIABILITY APPLICATION

1. APPLICANT:

FIRST NAMED INSURED AND OTHER NAMED INSUREDS:

FULL ADDRESS:

2. PRODUCER:

PRODUCER NAME AND ADDRESS:

PRODUCER CONTACT(S):

PHONE NO.:

FAX NO.:

3. INSPECTION CONTACT(S)

INSPECTION:

TELEPHONE NO.:

ACCOUNTING RECORDS:

TELEPHONE NO.:

4. PREMISES INFORMATION:

FULL ADDRESS , INTEREST YR. BUILT PART OCCUPIED

5. DESCRIPTION OF OPERATIONS:

NATURE OF BUSINESS / COMPLETE DESCRIPTION OF OPERATIONS:

YEARS IN BUSINESS? (IF LESS THAN FIVE YEARS,
ATTACH OWNER'S/MANAGEMENT'S RESUMES):

YEARS

6. EXPOSURE INFORMATION

NATURE OF OPERATION CURRENT YEAR GROSS SALES CURRENT YEAR FIELD PAYROLL ESTIMATED FOR NEXT YEARS GROSS SALES ESTIMATED FOR NEXT YEAR FIELD PAYROLL
TOTAL




7. MARINE VERSUS NON MARINE:

PERCENT OF RECEIPTS DERIVED FROM MARINE RELATED OPERATION: MARINE OPERATIONS: NON MARINE OPERATIONS:

8. PROPOSED POLICY TERM:

FROM: TO: TIME:

9. LIMIT/DEDUCTIBLE REQUESTED:

LIMIT: $

DEDUCTIBLE: $

() PER CLAIM

() PER OCCURRENCE

10. EXPIRING INFORMATION

CARRIER:

LIMIT: $

DEDUCTIBLE: $

RATE:

% PREMIUM: $

11. GENERAL INFORMATION (EXPLAIN ALL "YES" RESPONSES):

a. IS THE APPLICANT A SUBSIDIARY OF ANOTHER ENTITY OR DOES THE APPLICANT HAVE ANY SUBSIDIARIES?

b. HAS THE COVERAGE BEING REQUESTED BEEN CANCELED OR NON RENEWED DURING THE PRIOR FIVE YEARS? IF YES, EXPLAIN BELOW.

c. ARE ANY MEDICAL FACILITIES PROVIDED OR DOCTORS EMPLOYED/CONTRACTED?

d. WERE ANY OPERATIONS SOLD, ACQUIRED, OR DISCONTINUED IN THE LAST FIVE (5) YEARS?

e. DOES THE APPLICANT RENT, LEASE OR LOAN MACHINERY, TOOLS OR EQUIPMENT (OTHER THAN WATERCRAFT) TO OTHERS WITH OR WITHOUT OPERATOR?

f. DOES THE APPLICANT HAVE A SWIMMING POOL ON THE PREMISES OR ARE ANY RECREATIONAL FACILITIES PROVIDED?

g DOES THE APPLICANT SPONSOR OR PLAN TO SPONSOR ANY SPORTING OR SOCIAL EVENTS?

h. ARE ANY STRUCTURAL ALTERATIONS OR DEMOLITION EXPOSURES CONTEMPLATED?

i. DOES THE APPLICANT DRAW PLANS, DESIGNS OR SPECIFICATIONS?

j. DO ANY OPERATIONS INCLUDE EXCAVATION, TUNNELING, UNDERGROUND WORK OR EARTH MOVING?

k. DOES THE APPLICANT OWN, OPERATE, LEASE, BORROW OR CHARTER ANY WATERCRAFT?

l. ARE ALL WATERCRAFT IN 12.j. ABOVE SEPARATELY COVERED BY PROTECTION AND INDEMNITY INSURANCE INCLUDING CONTRACTUAL LIABILITY, BLANKET ADDITIONAL INSURED & WAIVER OF SUBROGATION, OTHER THAN OWNER AND IN REM COVERAGE? (IF YES, DESIGNATE BELOW THE P&I COVERAGE FORM USED. IF NO, EXPLAIN BELOW)

m. IS THE APPLICANT A NON-SUBSCRIBER TO ANY STATE AND/OR FEDERAL WORKERS COMPENSATION STATUTES?

n. DOES THE APPLICANT PURCHASE COVERAGE EXCESS OF THIS INSURANCE?
IF YES, WHAT LIMITS:
$


o. DOES THE APPLICANT PURCHASE MARITIME EMPLOYER'S LIABILITY INSURANCE?
IF YES, IS THE ALTERNATE EMPLOYER ENDORSEMENT PROVIDED?


p. DOES THE INSURED PURCHASE E&O AND D&O INSURANCE?
IF YES, WHAT LIMITS ARE PURCHASED?
$


q. DOES THE APPLICANT EMPLOY OR UTILIZE THE SERVICES OF ANY COMMERCIAL DIVERS?

r. IN THE LAST FIVE YEARS HAS THE APPLICANT OR ANY PREDECESSOR COMPANY EVER FILED FOR BANKRUPTCY PROTECTION?

REMARKS:

12. GENERAL INFORMATION (CONTINUED):

s. LIST THE PRINCIPAL STATES AND/OR OTHER LOCATIONS IN WHICH OPERATIONS ARE CONDUCTED:

t. LIST THE PRINCIPAL ENTITIES OR CORPORATIONS FOR WHICH WORK IS PERFORMED:

u. WHAT IS THE PERCENT OF WORK PERFORMED FOR OTHERS WHERE INDEMNITY / RELEASE / HOLD HARMLESS AGREEMENTS ARE GIVEN IN FAVOR OF THE OTHER PARTY?
%

13. LEASED / TEMPORARY WORKERS / SUBCONTRACTORS:

LEASED WORKERS TEMPORARY WORKERS INDEP / SUB CONTRACTORS
a. DOES THE APPLICANT UTILIZE?
b. ARE THERE INDEMNITY AGREEMENTS IN PLACE IN THE APPLICANT'S FAVOR WITH THE PROVIDER OF?
c. IS THE APPLICANT NAMED AS AN ALTERNATE EMPLOYER ON THE PROVIDER'S WORK COMP. POLICY?
d. ARE CERTIFICATES OF INSURANCE OBTAINED FROM ALL PROVIDERS?
e. DOES THE APPLICANT PROVIDE WORKERS COMPENSATION COVERAGE FOR THESE WORKERS?
f. WHAT WAS THE APPLICANT'S COST FOR THIS SERVICE OVER THE PAST TWELVE MONTHS?
g. WHAT ARE THE MINIMUM CGL LIMITS REQUIRED FROM THE PROVIDER?

h. IF THE ANSWER TO "a" IS YES, ATTACH A COPY OF THE STANDARD AGREEMENT / WORK ORDER USED. IF NO AGREEMENT OR WORK ORDER IS USED, PLEASE EXPLAIN:

i. IF SUBCONTRACTORS ARE USED:

What percent of work is subcontracted out?

Under whose direction and control do they work?

What is the nature of the work subcontracted out?

14. ENVIRONMENTAL/SAFETY (EXPLAIN ALL "YES" RESPONSES)"

a. DO OPERATIONS INVOLVE STORING, TREATING, DISCHARGING, APPLYING, DISPOSING, OR TRANSPORTING OF HAZARDOUS MATERIAL OR WASTE? IF YES, EXPLAIN BELOW THE COMPOSITION AND HOW THEY ARE STORED AND DISPOSED OF?

b. IS THERE ANY EXPOSURE TO FLAMMABLES, EXPLOSIVES, OR CHEMICALS?

c. IS THERE ANY CATASTROPHE EXPOSURE THAT YOU ARE AWARE OF?

d. ARE ALL TRANSPORTERS AND/OR HANDLERS AND/OR DISPOSAL COMPANIES EPA CERTIFIED AND PROPERLY INSURED?

e. ARE AIR EMISSIONS AND EFFLUENT DISCHARGES MONITORED?

f. IS THE APPLICANT IN NON-COMPLIANCE WITH ANY STATUTES, STANDARDS, OR OTHER GOVERNMENT REGULATIONS RELATING TO THE PROTECTION OF THE ENVIRONMENT?

g. IS A FORMAL SAFETY PROGRAM IN OPERATION?

h. WHO IS RESPONSIBLE FOR SAFETY, ENVIRONMENTAL SAFETY AND CONTROL? (INCLUDE NAME, TITLE, YEARS EXPERIENCE IN THIS JOB AND REPORTING RELATIONSHIPS)

REMARKS:

15. PRODUCTS/COMPLETED OPERATIONS (EXPLAIN ALL "YES" RESPONSES)

PRODUCT(S) ANNUAL GROSS SALES ($) # OF UNITS TIME IN MARKET (YRS) EXPECTED LIFE (YRS) INTENDED USE PRINCIPAL COMPONENTS

a. DOES THE APPLICANT MANUFACTURE, INSTALL, SERVICE OR DEMONSTRATE
ANY PRODUCTS?

b. IF APPLICANT ANSWERED "YES" TO QUESTION "a" ABOVE, ARE ANY OF THESE PRODUCTS INTENDED FOR USE OUTSIDE THE MARITIME INDUSTRY?

c. DOES THE APPLICANT CONDUCT RESEARCH AND DEVELOPMENT OR ARE NEW PRODUCTS PLANNED?

d. DOES THE APPLICANT PROVIDE GUARANTEES, WARRANTIES OR HOLD HARMLESS AGREEMENTS WITH RESPECT TO ANY PRODUCTS?

e. HAVE ANY PRODUCTS BEEN RECALLED, DISCONTINUED, OR MATERIALLY ALTERED?

f. ARE PRODUCTS OF OTHERS SOLD OR RE-PACKAGED UNDER THE APPLICANT'S LABEL?

g. ARE PRODUCTS SOLD UNDER THE LABEL OF OTHERS?

h. DOES ANY NAMED INSURED SELL TO OTHER NAMED INSUREDS?

REMARKS:

16. INDICATE APPLICATION SUPPLEMENTS ATTACHED/ COVERAGES REQUESTED:

IDENTITY OTHER ENDORSEMENTS BEING REQUESTED:

17. LOSS RECORD

ATTACH A FIVE PLUS CURRENT YEAR DETAIL "LOSS RECORD SUPPLEMENT" FOR ALL THE COVERAGES BEING REQUESTED IN ITEM 16, ABOVE.

OR CHECK HERE IF NO LOSSES FOR THIS PERIOD. Yes


18. SIGNATURES

APPLICANT'S SIGNATURE

PRODUCER'S SIGNATURE:

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