MARINE HULL PROPOSAL FORM
Applicant
Profile
Company Name :
_______________________________________________________________________________
Address
:_______________________________________________________________________________
Email and Website :
_____________________________________________________________________________
Applicant’s Interest :
____________________________________________________________________________
Date Company established :
______________________________________________________________________
Description of Business :
_________________________________________________________________________
Qualifications / Years experience of Technical Operation
Team : _________________________________________
Number of Vessels owned and managed during the last 5
years : ________________________________________
Has the Ship owner / Manager traded under any other names
within last 5 years? o Yes o No
If yes, please specify
:___________________________________________________________________________
Subject
Matter
Insured If more than one vessel, please provide
information in a separate sheet.
Vessel Name _____________________________ Ex-Name
__________________________________________
Type of Vessel
___________________________
Use of Vessel _______________________________________
Material of Hull ___________________________ Place Built _________________________________________
Year Built ________________________________ Flag ______________________________________________
Class ____________________________________ GRT ____________ DWT _____________ NRT ___________
Dimension ________________________________ Nationality
_________________________________________
Type of Engine(s), manufacturer and date of make
____________________________________________________
Horse Power_______________________________ Maximum designed speed with full load
_________________
Trading Areas
__________________________________________________________________________________
Type of Trade / Cargo carried
_____________________________________________________________________
Number and Nationality of Crew
___________________________________________________________________
If passenger vessel/craft, state
capacity
Type of other equipment’s and installations WIRELESS
TELEGRAPHY, RADIO, RADAR, GYROCOMPASS ECHO-SOUNDER OR OTHERS
Manufacturer and date of make
State Serial and model number
Boilers, manufacturer and date of make
Type of fuel used
Storage and quantity
of fuel carried
State number of officers and crews
required to operate vessel
State number and Type of Fire Extinguisher and pumps
State number and Type of Safety
equipment normally carried
Will others be permitted to sail/or
navigate the vessel? If “yes”,
please give name(s), position, nationality, qualification and experience of such persons.
Where is the vessel normally
moored?
State cruising/trading confines or limit
State Voyage or Period of Insurance cover required
Vessel last surveyed
_____________________________________________________________________________
Name of Surveyor ______________________________________________________________________________
Date last Special Survey For Hull ________________________
For Machinery _____________________
Date Next Special Survey For Hull ________________________
For Machinery _____________________
Date Next Dry docking survey ________________________
Please supply of the last survey report and dry docking
report, Documents Enclosed:
o Latest Survey o Safety Equipment Certificate
o Valuation Report o Certificate of Competency of Master and
Officers
o Photographs of Vessel o Classification Certificate
o Ship’s License o License Certificate
o Loading Certificate
Were all Surveyors recommendations, if any, fully
rectified?
o Yes o No
If yes, please specify:
___________________________________________________________________________
Has there been any change of class of the vessel? o Yes o No
If yes, state the reason why
______________________________________________________________________
Is Vessel Mortgaged or other finance agreement ? o Yes o No
If yes, Mortgagee’s Name :
______________________________________________________________________
Loan term : _______________________________________________________________________
Loan amount : _______________________________________________________________________
Approximate loan amount
outstanding : ______________________________________
Coverage /
Insured Value
PLEASE
STATE THE CURRENCY YOU WISH TO INSURED
|
S/N |
Items |
Value (=N=) |
|
1 |
Hull,
Machinery, Gear & Equipment’s |
|
|
2 |
Dinghy |
|
|
3 |
Outboard |
|
|
4 |
Motor |
|
|
5 |
Personal
Effects |
|
1. STATE INDIVIDUAL ITEMS OF
PERSONAL EFFECTS ON A SEPARATE SHEET OF PAPER.
2. STATE INDIVIDUAL HIGH VALUE ITEMS OF EQUIPMENT YOU WISH
INSURERS TO BE AWARE OF ON A SEPARATE SHEETOF PAPER.
Increased Value :
_______________________________________________________________________________
War Risks : ____________________________________________________________________________________
Mortgagees Interests :
___________________________________________________________________________
PROTECTION
& INDEMNITY COVER REQUIRED:
_______________________________________________________
Expected Premium: __________________________ Source of Funds: ___________________________
Details of Insurance Cover Required
General Conditions: o ITC-Hulls o FPAU o Total Loss
Collision Liability: o No o Yes
If yes, please tick proportion required: o 1/4th o 3/4th o 4/4th
Include restricted P&I Cover: o No o Yes
Others, please specify: ___________________________________________________________________________
Claims
Details
Please provide loss history for the last five (5) years,
including incidents reported and claims not paid, as well as all claims or
incidents that would resulted in a claim had proposed cover been in force.
Date of Accident Details
and Cause of Loss Claim
Paid ($) Outstanding Claim
($) Status
________________
_____________________
____________ __________________ _______
________________
_____________________
____________ __________________ _______
________________
_____________________
____________ __________________ _______
Details of
Current Insurance
Insurer :
______________________________________________________________________________________
Insured Value :
_________________________________________________________________________________
Rate / Premium :
_______________________________________________________________________________
Deductible :
___________________________________________________________________________________
Coverage :
____________________________________________________________________________________
Others
Has any insurer declined or cancelled your vessel
insurance? o Yes o No
Any other information relating to the proposed risk? o Yes o No
If yes, please specify:
____________________________________________________________________________
Declaration IMPORTANT
: You are to disclose in this application form, fully and faithfully, all the
material facts you know or ought to know. Otherwise, you may not receive any
benefit from you policy.
We declare that the information and answers given in this
form are true and correct to the best of our knowledge, and we have not
misstated or suppressed any material facts that may influence the assessment of
the risk. We also understand that completion of this form does not bind
insurers or mean we will accept this insurance but, it is agreed that this form
shall be the basis of contract should the insurance be effected.
Company’s Stamp and Signature
__________________________________________________________________
Name / Designation ___________________________________ Date _______________________________
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