Form Application for Terminal Operators


MARINE COMMERCIAL LIABILITY SUPPLEMENTARY INFORMATION FOR TERMINAL OPERATORS

Name:

Address Line 1:

Address Line 2:

Telephone Number:

Number of years in business:

Number of years under current management:

Location(s):

Is your facility lighted?

Is your facility Fenced?

Describe means of public access:

Please describe your fire alarm systems:

Please describe your security alarm systems:

Is there a watchman?

Number of hours on duty?

Clock Punch?

Describe loading and unloading equipment:

What is the average value of all cargo stored at the terminal? $

What is the maximum value? $

What type of documentation is issued for cargo storage? (please attach)

What type of cargos are stored at the terminal?

Type % "Check" if stored Outside

Please attach a diagram of the facility and provide the construction and fire protection of each building (Give as much detail as possible.):

Are combustible materials kept in a separate area?

Is there a municipal or volunteer fire department?

What is the distance from the nearest fire fighting facility?

Number of fire hydrants at your facility?

Number of fire extinguishers at your facility?

Kind:

Size:

Who is your current insurance carrier?

How long insured by them?

Has your insurance ever been cancelled?

If yes, why and by whom?

Limit of liability requested ($)?

Deductible ($)?

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

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

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 applicant's favor?

Waiver of subrogation?

Are certificates of insurance obtained?

What limits?

List all losses during the last 5 years (amounts should include deductible). Please include 'Date of Loss', 'Amount Paid', 'Amount Outstanding', and a 'Description of loss' for each entry.

Name of Contact for arranging yard inspection:

Telephone Number:

Producer remarks:

Please attach any additional documentation here

Additional documentation 1:

Additional documentation 2:

Additional documentation 3:

Important Note:
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:

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