Electronics Application

Vessel Name*

Named Assured

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email Address*

Phone*

Vessel Details

Year Built

LOA

Gross Tons

Date of Last Vessel Survey

Surveyor

Market Value

Replacement Cost

Vessel Sum Insured

Electronics Details

Electronics Value

Requested Sum Insured

Claims

Please provide details of all Electronics claims within the past 5 years for this and any other vessels owned or operated by you whether insured or not:

Most Recent Survey

Please attach a copy of the most recent survey, including a schedule of the electronics.

Max. file size: 50 MB.

I HEREBY DECLARE THAT THE PARTICULARS AND ANSWERS GIVEN IN THIS APPLICATION ARE IN EVERY RESPECT TRUE AND CORRECT AND THAT I HAVE NOT WITHELD ANY INFORMATION WHICH COULD INFLUENCE THE DECISION OF THE COMPANY IN REGARD TO IT’S ACCEPTANCE.

Signature*

Date

Name

This field is for validation purposes and should be left unchanged.

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Electronics Details

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