Application for Marine Artisans / Marina Operators

Please complete the attached questionnaire as fully as possible.

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Proposed Effective Date
MM slash DD slash YYYY
Proposed Effective Time

: Hours

Minutes
Expiration Date
MM slash DD slash YYYY
Expiration Time

: Hours

Minutes
New Policy*
- Yes
- No
Expiring Policy Date*
MM slash DD slash YYYY
Name of Insured/s
Email Address*
Phone*
Mailing Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Location
Number of years in business
Interest of the Named Insured/s in the described premises
- Owner
- Tenant
- General Lease
Limit Required (per occurrence)
Deductible Required (per occurrence)
Underwriting Information
How long in operation under present management?*
Name(s) and Past Experience(s) of key personnel*
Number of full-time employees*
Number of part-time employees*
Annual Payroll*
Fire Protection
Public*
Paid*
Volunteer*
Distance from premises*
Number of fire hydrants on premises*
Number of fire extinguishers*
Racked storage?*
How many sprinkler heads per pod?*
Please, give a full description of other fire protections*
Is formal safety program in force?*
Person to contact for survey*
Are night-watchmen employed on premises?
Are premises floodlit at night?
Is storage area fenced in?
Describe fencing*
Does the facility own any automobiles?
Is hired and non-owned auto liability required?
Have you ever had Insurance declined, non-renewed or cancelled?*
Please provide full details*

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Anticipated Annual Gross Receipts for Operation
Mooring / slip rental*
Ship store / marine store*
Store - Alcoholic Beverage*
Storage (normal)*
Restaurant / Snack Bar*
Restaurant - Alcoholic Beverage*
Storage (racked)*
Hotel / Campground*
Fueling*
New / Used Boat Sales*
Repairs / Servicing*
Other
Claims and Losses Over the Last 5 Years
List all losses and give full details*
Specific Information in Respect of Ship Repairers or Marine Artisans
Details of yard facilities (i.e. wet / dry docks, piers, wharves, onshore facilities, etc.)*
Gross receipts during the past 12 months*
Estimated gross receipts for next 12 months*
Types of repairs carried out
Repairs and servicing carried out:
Servicing
Mechanical
Electrical
Rigging
Painting
Welding / burning
Other
Describe
Number of vessels repaired annually
Types of vessels repaired*
Maximum Size (Tonnage)
Average value per vessel
Maximum value per vessel
If any reconstruction, fabrication, assembly, or other onshore work is done, please give details and percentage of operations.
Movement of third party property by land or water is automatically covered with 25 miles of scheduled premises. Any movement in excess of 25 miles must be pre-approved and any additional premium paid. If movement in excess of 25 miles normally occurs on a regular basis:
Average number of times per month
Average length of movement (in miles)
Fraud Warning
Any person who knowingly, and with the intent to defraud any insurance company or other person, files an application for insurance or a statement of claim containing any materially false information or conceals for the purpose of misleading information concerning any fact material, thereto commits a fraudulent insurance act, which is a crime and subjects such a person to criminal and civil penalties.
Applicant's Signature*
Date*
MM slash DD slash YYYY
Comments
This field is for validation purposes and should be left unchanged.

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Application for Marine Artisans / Marina Operators

Step 1 of 2

Underwriting Information

Anticipated Annual Gross Receipts for Operation

Claims and Losses Over the Last 5 Years

Specific Information in Respect of Ship Repairers or Marine Artisans

Fraud Warning

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