Form Application for Stevedores


MARINE COMMERCIAL LIABILITY
SUPPLEMENTARY INFORMATION FOR STEVEDORES

Applicant's Name:

Address Line 1:

Address Line 2:

Telephone Number:

Number of years in business:

Number of years under current management:

Location(s):

Please advise the following for each type of cargo separately

5. General Break-bulk Cargoes

Tonnage Handled Last 12 months:

Tonnage Estimated next 12 months:

Method of handling:

 

Refigerated/chilled Cargoes

Tonnage Handled Last 12 months:

Tonnage Estimated next 12 months:

Method of handling:

 

Bulk Grain

Tonnage Handled Last 12 months:

Tonnage Estimated next 12 months:

Method of handling:

 

Coal/Bulk Ores

Tonnage Handled Last 12 months:

Tonnage Estimated next 12 months:

Method of handling:

 

Liquid Chemicals

Tonnage Handled Last 12 months:

Tonnage Estimated next 12 months:

Method of handling:

 

Bulk Oils

Tonnage Handled Last 12 months:

Tonnage Estimated next 12 months:

Method of handling:

 

Scrap Metals

Tonnage Handled Last 12 months:

Tonnage Estimated next 12 months:

Method of handling:

 

Heavy Lift Cargoes

Tonnage Handled Last 12 months:

Tonnage Estimated next 12 months:

Method of handling:

 

Containerized

Tonnage Handled Last 12 months:

Tonnage Estimated next 12 months:

Method of handling:

 

Automobiles

Tonnage Handled Last 12 months:

Tonnage Estimated next 12 months:

Method of handling:

 

Explosive, Flammable, or Toxic Cargoes

Tonnage Handled Last 12 months:

Tonnage Estimated next 12 months:

Method of handling:

 

Machinery

Tonnage Handled Last 12 months:

Tonnage Estimated next 12 months:

Method of handling:

 

 

6. Total Annual Gross Receipts last 5 Years:

Year1:

Amount1:

Year2:

Amount2:

Year3:

Amount3:

Year4:

Amount4:

Year5:

Amount5:

 

7. For liquid cargoes in bulk, are you responsible for hook-up of pipes:

a) Aboard Ship:

b) At shoreside connection/tank farms?

 

8. Are you responsible for properly and safely stowing as well as loading or unloading cargoes?

9. Do you perform lighterage operations?

If "Yes":

a) How far offshore are the lightered ships (miles)?

b) What kind of cargoes are involved?

 

10. Do you own or lease the terminal you service?

11. Do you operate using your own cargo handling equipment?

12. If Ship's handling equipment is used, what percentage of the time does this happen?

13. Whose employees operate the equipment? Yours or the Ship's?

14. If Ship's crew operate the equipment, do they do so under your direction?

15. Is there a municipal or volunteer fire department? YesNo

16. What is the distance from the nearest fire fighting facility?

17. Number of fire hydrants at your facility?

18. Number of fire extinguishers at your facility?

19. Who is your current insurance carrier?

20. How long insured by them?

21. Has your insurance ever been cancelled?

If yes, why and by whom?

22. Limit of liability requested ($):

Limit of Deductible requested ($):

23. If our quotation is accepted, what is date of attachment?

24. Current premiums? (i.e. Minimum & Deposit and adjustment rate):

25. Are revenues generated from other than the marine operations described above?

If so, provide details:

26. Does applicant use employee leasing services and/or temporary workers?

If so, are there hold harmless/indemnity agreements in place in the applicant's favor?

Waiver of subrogation?

Are certificates of insurance obtained?

What limits?

 

 

27. List all losses during the last 5 years (amounts should include deductible):

Loss 1

Date of Loss:

Amount Paid:

Amount Outstanding:

Description of Loss:

Loss 2

Date of Loss:

Amount Paid:

Amount Outstanding:

Description of Loss:

Loss 3

Date of Loss:

Amount Paid:

Amount Outstanding:

Description of Loss:

Loss 4

Date of Loss:

Amount Paid:

Amount Outstanding:

Description of Loss:

Loss 5

Date of Loss:

Amount Paid:

Amount Outstanding:

Description of Loss:

 

 

28. Contact and phone number to arrange an inspection:

29. Producer remarks:

 

 

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's Signature:

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

Company Title:

Date: