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.