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Quotation Request Form - P&I Insurance
5. Current Insurance Arrangements
a. Name of current P&I insurer
b. Name of current H&M insurer
c. Extent of current Collision (RDC) / Fixed & Floating Objects (FFO) / Removal of Wreck Cover under H&M Policy
i. Collision with other vessels (RDC) Excluded absolutely Including 3/4th collision liability Including 4/4ths collision liability
ii. Fixed & Floating Objects (FFO) Excluded absolutely Included to H&M value
iii. Removal of Wreck Excluded absolutely Included to H&M value Other (please specify below)
d. Please provide details of any other liability cover in place.
6. Claims History
Please provide details of any incident over the last ve years that has given rise to a liability claim on insurers, may yet give rise to a
claim, or would have given rise to a claim on insurers had P&I insurance cover been in place.
7. Crew
Please supply number and nationality of ocers and ratings employed on board vessels.
Nationality Total Number of Crew
Date of Loss Type of Loss
Total Value
of Claim
Total Paid
Claim to Date
Total Estimated
Claim
Policy Excess
