Form Application Hull P & I — Commercial Vessels

Application for Quotation
Hull And Protection & Indemnity Insurance – Commercial Vessels

Name of Applicant:

Owners:

Occupation(s):

Business Address Line 1:

Business Address Line 2:

Telephone Number:

Mortgagee:

Mortgagee Address Line 1:

Mortgagee Address Line 2:



Hull Coverage

Vessel 1

Name of Vessel:

Year Built:

Gross Ton:

Material of Hull:

Type of Propulsion & H.P.:

Type of Vessel:

Length & Beam:

Date of Last Drydock:

Desired Amount of Insurance:

Vessel 2

Name of Vessel:

Year Built:

Gross Ton:

Material of Hull:

Type of Propulsion & H.P.:

Type of Vessel:

Length & Beam:

Date of Last Drydock:

Desired Amount of Insurance:

Vessel 3

Name of Vessel:

Year Built:

Gross Ton:

Material of Hull:

Type of Propulsion & H.P.:

Type of Vessel:

Length & Beam:

Date of Last Drydock:

Desired Amount of Insurance:

Vessel 4

Name of Vessel:

Year Built:

Gross Ton:

Material of Hull:

Type of Propulsion & H.P.:

Type of Vessel:

Length & Beam:

Date of Last Drydock:

Desired Amount of Insurance:

Vessel 5

Name of Vessel:

Year Built:

Gross Ton:

Material of Hull:

Type of Propulsion & H.P.:

Type of Vessel:

Length & Beam:

Date of Last Drydock:

Desired Amount of Insurance:

Vessel 6

Name of Vessel:

Year Built:

Gross Ton:

Material of Hull:

Type of Propulsion & H.P.:

Type of Vessel:

Length & Beam:

Date of Last Drydock:

Desired Amount of Insurance:



Protection & Indemnity Coverage

Vessel 1

Name of Vessel:

Type of Cargo Carried:

No. Crew (Excl. Owner):

Max # of Passengers Cert. By U.S.C.G.:

Liability of Vessels & Cargo in tow desired:

Desired Amount of Insurance:

Vessel 2

Name of Vessel:

Type of Cargo Carried:

No. Crew (Excl. Owner):

Max # of Passengers Cert. By U.S.C.G.:

Liability of Vessels & Cargo in tow desired:

Desired Amount of Insurance:

Vessel 3

Name of Vessel:

Type of Cargo Carried:

No. Crew (Excl. Owner):

Max # of Passengers Cert. By U.S.C.G.:

Liability of Vessels & Cargo in tow desired:

Desired Amount of Insurance:

Vessel 4

Name of Vessel:

Type of Cargo Carried:

No. Crew (Excl. Owner):

Max # of Passengers Cert. By U.S.C.G.:

Liability of Vessels & Cargo in tow desired:

Desired Amount of Insurance:

Vessel 5

Name of Vessel:

Type of Cargo Carried:

No. Crew (Excl. Owner):

Max # of Passengers Cert. By U.S.C.G.:

Liability of Vessels & Cargo in tow desired:

Desired Amount of Insurance:

Vessel 6

Name of Vessel:

Type of Cargo Carried:

No. Crew (Excl. Owner):

Max # of Passengers Cert. By U.S.C.G.:

Liability of Vessels & Cargo in tow desired:

Desired Amount of Insurance:



General Description of Operation

Type of work employed in:

Experience of Employee's and Licenses:

Towboats only: Type and number of vessels in tow and copy of towage contract:

Non-propelled Vessels: Give details of tower and copy of towage contract:

Are Towers released?

By whom?

Navigation limits required:

Is Watchman Service Provided?

Where can vessel(s) be inspected (Please provide updated Surveys for each vessel):

Is vessel(s) ever Laid-up?

Vessel Location:

Date:

Is the Vessel operated by Owner?

Vessel 1

Vessel Involved:

Date of Loss:

Location of Accident:

Details of Accident:

Gross Amount of Loss before any deductible:

Current Status, Paid or Outstanding:

Vessel 2

Vessel Involved:

Date of Loss:

Location of Accident:

Details of Accident:

Gross Amount of Loss before any deductible:

Current Status, Paid or Outstanding:

Vessel 3

Vessel Involved:

Date of Loss:

Location of Accident:

Details of Accident:

Gross Amount of Loss before any deductible:

Current Status, Paid or Outstanding:

Vessel 4

Vessel Involved:

Date of Loss:

Location of Accident:

Details of Accident:

Gross Amount of Loss before any deductible:

Current Status, Paid or Outstanding:

Vessel 5

Vessel Involved:

Date of Loss:

Location of Accident:

Details of Accident:

Gross Amount of Loss before any deductible:

Current Status, Paid or Outstanding:

Vessel 6

Vessel Involved:

Date of Loss:

Location of Accident:

Details of Accident:

Gross Amount of Loss before any deductible:

Current Status, Paid or Outstanding:

Special Information

Does this placing include all vessels operated by the Assured or affiliated or subsidiary companies?

If not, explain:

Present Insuring Company:

Provide copies of current policies if available?

Has any company ever canceled insurance for this owner?

If "yes", with what Company and on what terms?

ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION OF INSURANCE CONTAINING ANY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRADULENT INSURANCE ACT, WHICH IS A CRIME.

Signing this form does not bind the Applicant to purchase the insurance or the Company to accept the risk, but it is agreed that this form shall be the basis of the contract should a policy be issued.

Date:

Signature of Applicant:

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



Questions to be answered by Agent

Is the Owner well and favorably known to you?

Do you unqualifiedly recommend the moral and physical risk?

List supporting insurance in this Company showing policy number and premium:

Agent:

Address:

Please attach any additional forms using the following fields: