Fillable SHIPREPAIRERS LEGAL LIABILITY INSURANCE Supplemental Application for Please (Risk Placement Services, Inc.)

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SHIPREPAIRERS LEGAL LIABILITY INSURANCE Supplemental Application for Please (Risk Placement Services, Inc.)

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Supplemental Application for
SHIPREPAIRERS
LEGAL
LIABILITY INSURANCE
to be used with standardized
industry
Commercial Insurance
Applications
Applicant Information Section, Commercial General Liability Section (as
needed)
Please Print or Type
Name of Applicant
Policy Period Limit Required Deductible Required
From: To: $ $
GENERAL INFORMATION —
VESSELS
Location of Yard (Exact Address)
Type of Vessels Worked Upon:
Steel % Fiberglass % Wood % Aluminum % Ferro Cement %
Type of work:
Engine % Boiler % Hull % Electrical % Painting % Welding %
Do You Perform Gas Freeing Operations?
Yes No If “yes,” no. of vessels gas freed in one year?
NOTE: If not gas freeing exposures will be expressly excluded from this insurance.
Does the In
sured employ one of the following as required?
Full-Time Gas Free Chemist Outside Subcontracted Chemist
If an outside chemist is subcontracted, does the Insured currently require proof of liability insurance
(insurance certificate) from the chemist or his employer in a minimum amount of $1,000,000 .......................................................................................................... Yes No
No. of Drydocks
No. of Railways
No. of Repair Piers
No. of Vessels Drydocked in Last Year
No. of Vessels Repaired in Yard in Last Year
No. of Vessels Repaired outside of Yard in Last Year
No. of Vessels Hauled out in Last Year
AVERAGE VALUE OF VESSEL: $
MAXIMUM VALUE OF VESSEL: $
BUILDING
CONSTRUCTION
BUILDINGS
CONSTRUCTION
MATERIAL (WOOD)
1. 1.
2. 2.
3.
3.
4. 4.
Are buildings
sprinklered?
................................................................................................................................................................................. Yes No
FIRE
PROTECTION
Public Fire Department
Public Fire Hydrants
Public Fire Mains
Paid Volunteer
How Many?
How Far Distant?
Size:
Pressure:
Private Fire Protection (If “yes,” describe)
Yes No
SECURITY
How Many Watchman Employed? How Many on Each Shift? Watchlocks?
Yes
No
Is yard fenced in, with guard at gate, when yard is operating?
Yes No
How long has shipyard been in operation under present management? (Give prior business name, if any)
ATTACH SEPARATE SHEET GIVING NAMES AND PAST EXPERIENCE OF KEY PERSONNEL
GROSS
RECEIPTS
!
!
Gross
Receipts
For
Past
3
years:
$
YR
$
YR
$
YR
!
Loss
Experience
!
Please attach loss experience for the past 5 years with amounts paid and outstanding (including uninsured losses). Loss
runs from prior carriers are preferred.
!
!
Is released secured limiting
liability?
................................................................................................................................................................. Yes No
!
If “yes,”
amount: ................................................................................................................................................................................
$___________________
!
COMMENTS
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
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Agent Date
!
Agent’s Address
!
!
!
FURNISH COPY OF PRESENT POLICY AND ANY
CONTRACTUAL AGREEMENT
WHICH
INCREASES
THE APPLICANT’S LIABILITY IN
ANY
WAY
!
!
ANY PERSON WHO, KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER
PERSON, FILES AN APPLICATION FOR INSURANCE, CONTAINING ANY MATERIALLY FALSE INFORMATION,
OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL
THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME.
!
!
I understand that the above information, which is correct and complete to the best of my knowledge, is to be the basis of
insurance, if granted, but does not oblige me to accept the insurance, nor the company to accept the risk.
!
Date: Applicants Signature:
!
Time:
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SHIPREPAIRERS LEGAL LIABILITY INSURANCE Supplemental Application for Please (Risk Placement Services, Inc.)

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Completed 30 July 2020

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