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Maritime Employers’ Liability Application

Step 1 of 2

Details of Insured
Name
First Last
Email*
Phone*
Address
Street Address Address Line 2 City State ZIP Code
Business Type
Number of years in business
Total number of employees
Overwater Information
Description of overwater operations
Total no. of employees exposed overwater per annum
Maximum number of employees exposed overwater at any one time
Watercraft
Do employees spend more than 25% of their time in employment on-board watercraft*, either on or off duty?
Please provide further details
Does insured own/operate any watercraft*?
Please provide further details
Are these watercraft* used only to transport employees, who are subject to this application, as passengers, to and/or from a place of work or a specific job site?
Does the insured purchase a separate P&I insurance policy which covers the captain and the crew of the owned or operated watercraft*?
Does the owned or operated watercraft have a dedicated captain or crew?
What percentage of overwater operations are performed on:
Watercraft*, barges, etc.
Jack-ups, semi-submersibles, etc.
Offshore fixed platforms
Do employees keep any of their tools or equipment on watercraft*?
If shipbuilding/ship repair do employees participate in trial trips?
Please provide number of trial trips per annum
Diving
Does the insured engage in any diving operations?
Total number of divers
Total number of tenders
Do tenders dive?
Type of diving
*The definition of a watercraft is a vessel or structure other than a fixed permanent platform, which is capable of navigation, either under own power or being towed. A jack-up, semi-submersible and similar structures are deemed to be vessels.

Gross Overwater Payroll
Workers Compensation Act...
Last 12 months (USD)
Next 12 months (USD)
LSHWA Dockside (excluding diving payroll): work done dockside including but not limited to work on docked watercraft*...
Last 12 months (USD)
Next 12 months (USD)
LSHWA Away from dockside (excluding diving payroll): work done onboard watercraft* over water away from dock by employees who do so for LESS THAN 25% of their total employment time...
Last 12 months (USD)
Next 12 months (USD)
Jones Act (excluding diving payroll): work done onboard watercraft* away from dock by employees who do so for more than 25% of their total employment time...
Because the insured purchases a separate P&I insurance policy which covers the captain and the crew of the owned or operated watercraft*, do not include the Jones Act payroll for these officers and crew.
Last 12 months (USD)
Next 12 months (USD)
Diving payroll...
Last 12 months (USD)
Next 12 months (USD)
*The definition of a watercraft is a vessel or structure other than a fixed permanent platform, which is capable of navigation, either under own power or being towed. A jack-up, semi-submersible and similar structures are deemed to be vessels.
Claims
Has the insured had any Jones Act claims, or incidents which could have given rise to a Jones Act claim, during the past five years?
Please provide further details
Policy Requirements
Inception date required
MM slash DD slash YYYY
Expiry date*
MM slash DD slash YYYY
Is this a single job/contract?
Limit required (USD)
Do you require TRIPRA cover?
It is understood and agreed that this proposal form forms part of this policy and that underwriters hereon shall rely upon this information to determine the acceptability, rate and coverage. It is further understood that any misrepresentation or omission shall constitute grounds for immediate cancellation of coverage and denial of claim, if any. It is further understood that the applicant and/or affiliated company is under a continuing obligation immediately to notify his underwriters through his agent of any material alteration to information given.

The undersigned is an authorized representative of the applicant and certifies that reasonable enquiry has been made to obtain the answers to questions on this application. He/she certifies that the answers are true, correct and complete to the best of his/her knowledge.
Signature*
Date*
MM slash DD slash YYYY
Email
This field is for validation purposes and should be left unchanged.

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