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COMMERCIAL HULL AND P&I APPLICATION HULL COVERAGE Amount (Risk Placement Services, Inc.)

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Name of
Applicant:
Owners:
Occupations(s):
Business
Address
Mortgagee:
Mortgagee’s
Address:
COMMERCIAL HULL AND P&I APPLICATION
Website
HULL COVERAGE
Name
of
Vessel
Year
Built
Gross
Ton.
Material
Of Hull
Type
of
Propulsion
&
H.P.
Type of
Vessel
Length
& Beam
Date
of
Last
Drydock
Desired
Amount
of
Insurance
PROTECTON & INDEMNITY COVERAGE
Name
of
Vessel
Type
of
Cargo
Carried
(excl.
Owner)
Passengers
Cert.
By
Liability
of
Vessels
&
Cargo in
tow
desired
Desired
Amount
of
Insurance
GENERAL DESCRIPTION OF OPERATION
Type of work employed in:
Experience of Employee’s and Licenses:
Towbo
ats only: Type and number of vessels in tow and copy of towage contract:
Non-prop
elled Vessels: Give details of tower and copy of towage contract:
Are To
wers released?
Navigation limits required:
Is Watchman Service Provided?
Where can vessel(s) be inspected?
Person to contact (name & phone #)
Attach recent surveys if available.
By whom?
Vessel
Involved
Date
of
Loss
Location
of
Accident
Details
of
Accident
Gross Amt of
Loss before
any deductible
Current
Status
Paid
or
Outstanding
Is vessel(s) ever Laid-up? Location: Dates:
Is the Vessel operated by
Owner?
FIVE
YEARS LOSS RECORD-All vessels owned or operated by the Assured including vessels sold or lost.
SPECIAL INFORMATION
Does this placing include all vessels operated by the Assured or affiliated or subsidiary companies?
If not, explain:
Present Insuring Company
Expiration date of current policy?
Attachment date if different than above.
Provide copies of current policies if available?
Has any company ever cancelled or non-renewed any insurance for this owner? (not applicable in MO)
Yes No
If
“yes”,
with
what
Company
and
on
what
terms?
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON
FILES AN APPLICATION OF INSURANCE CONTAINING ANY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE
OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRADULENT
INSURANCE ACT, WHICH IS A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON.
Signing this form does not bind the Applicant to purchase the insurance or the Company to accept the risk, but it is agreed that this form
shall be the basis of the contract should a policy be issued.
Date: , 20
Signature of Applicant
QUESTIONS TO BE ANSWERED BY AGENT
Is the Owner well and favorably known to you?
Do you unqualifiedly recommend the moral and physical risk?
List supporting insurance in this Company showing policy number and premium
AGENT ADDRESS
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COMMERCIAL HULL AND P&I APPLICATION HULL COVERAGE Amount (Risk Placement Services, Inc.)

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Completed 30 July 2020

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