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


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


Type of P&I Coverage

Class 1

Class 2

Limit Required for P&I


P&I Deductibles












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




The questionnaire must be signed by the applicant.

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