P&I and Hull & Machinery questionnaire form

(One form per vessel, please make sure this form is signed by the Owner or Manager)

Name of Assured (Registered Owner)


Full address


City incl. Postal code


Telephone number


Fax number


E-mail address


Loss payee


Name of vessel


Gross Tonnage / DW


Type of vessel


Type of use


Year built


Flag


Port of registry


Call Sign


Classification Society


Trading Area


IMO number


What is status on ISM Code compliance


Date of last dry dock


Date of last Special Survey


Outstanding Class items

If YES, provide copy of classification society’s letter/fax


Date of last P. & I. condition survey


Outstanding defects

If YES, provide copy of P. & I. Club’s letter/fax


Type of cargoes carried?


Are steel cargoes carried?


Are IMDG cargoes carried?

(If yes, please specify)


Number of crew on board


Nationality of crew


Is a Personal Accident Policy/Health

Care Plan in force?


Is there any Mortgagor? If YES what is Mortgagee?


Please give details of selection/pre-employment program carried out for new crew


Who/from where is nautical/technical management performed?


Who/from where is crew management performed?


Who/from where is chartering management performed?


Experience of managers and how many vessels were owned/ managed during last 5 years?


Is vessel regularly employed on period time charter?


If not, please indicate main stream of chartering activities


Period of insurance required


Name of present/latest P. & I. Insurer


Type of Coverage


Is RDC/FFO cover required?


Please provide details loss record for last 5 years


Value of the Vessel



Type of Coverage


Hull & Machinery Deductible

US$


Type of P&I Coverage

Class 1

Class 2

Limit Required for P&I

US$

P&I Deductibles

Cargo

US$


Pollution

US$


Crew

US$


RDC/FFO

US$


Others

US$







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.

Signed by


Date


Company


Signature


The questionnaire must be signed by the applicant.

The signing of this questionnaire does not bind the applicant to complete the insurance.