(One form per vessel, please make sure this form is signed by the Owner or Manager)
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Name of Assured (Registered Owner)
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Full address
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City incl. Postal code
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Telephone number
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Fax number
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E-mail address
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Loss payee
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Name of vessel
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Gross Tonnage / DW
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Type of vessel
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Type of use
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Year built
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Flag
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Port of registry
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Call Sign
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Classification Society
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Trading Area
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IMO number
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What is status on ISM Code compliance
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Date of last dry dock
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Date of last Special Survey
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Outstanding Class items
If YES, provide copy of classification society’s letter/fax
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Date of last P. & I. condition survey
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Outstanding defects
If YES, provide copy of P. & I. Club’s letter/fax
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Type of cargoes carried?
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Are steel cargoes carried?
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Are IMDG cargoes carried?
(If yes, please specify)
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Number of crew on board
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Nationality of crew
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Is a Personal Accident Policy/Health
Care Plan in force?
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Is there any Mortgagor? If YES what is Mortgagee?
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Please give details of selection/pre-employment program carried out for new crew
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Who/from where is nautical/technical management performed?
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Who/from where is crew management performed?
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Who/from where is chartering management performed?
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Experience of managers and how many vessels were owned/ managed during last 5 years?
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Is vessel regularly employed on period time charter?
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If not, please indicate main stream of chartering activities
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Period of insurance required
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Name of present/latest P. & I. Insurer
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Type of Coverage
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Is RDC/FFO cover required?
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Please provide details loss record for last 5 years
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Value of the Vessel
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Type of Coverage
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Hull & Machinery Deductible
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US$
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Type of P&I Coverage
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Class 1
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Class 2
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Limit Required for P&I
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US$
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P&I Deductibles
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Cargo
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US$
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Pollution
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US$
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Crew
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US$
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RDC/FFO
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US$
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Others
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US$
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IMPORTANT NOTE:
Information not covered by the questions in this questionnaire, but which would influence the risk assessment of the insurer, must be disclosed. If there is a failure to disclose such information, the insurance could be come void. If there are doubts whether additional information would be of influence, it should be disclosed.
Information not disclosed elsewhere:
The undersigned hereby declares that the questionnaires has been completed to the best of his/her knowledge and believe.
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Signed by
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Date
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Company
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Signature
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The questionnaire must be signed by the applicant.
The signing of this questionnaire does not bind the applicant to complete the insurance.