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Application for Marine Artisans / Marina Operators
Application for Marine Artisans / Marina Operators
Please complete the attached questionnaire as fully as possible.
Step
1
of
2
50%
Proposed Effective Date
MM slash DD slash YYYY
Proposed Effective Time
:
Hours
Minutes
AM
PM
Expiration Date
MM slash DD slash YYYY
Expiration Time
:
Hours
Minutes
AM
PM
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
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
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?
*
Yes
No
How many sprinkler heads per pod?
*
Please, give a full description of other fire protections
*
Is formal safety program in force?
*
Yes
No
Person to contact for survey
*
Are night-watchmen employed on premises?
Yes
No
Are premises floodlit at night?
Yes
No
Is storage area fenced in?
Yes
No
Describe fencing
*
Does the facility own any automobiles?
Yes
No
Is hired and non-owned auto liability required?
Yes
No
Have you ever had Insurance declined, non-renewed or cancelled?
*
Yes
No
Please provide full details
*
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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Forms
Application for Marine Insurance
Owner’s / Skipper’s Questionnaire
Sportfishing/Charter Vessel Application
Yacht Proposal Application
Yacht Additional Information Questionnaire
Application for Marine Artisans / Marina Operators
Application for Marina Operators
Maritime Employers’ Liability Application
Roto-Wing Aviation Application
Fixed Wing Aviation Application
Oil Pollution Application
Fishing Nets Application
Electronics Application
Cargo Insurance Application
Aquaculture Application
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