BUMBERSHOOT APPLICATION

1.	Name of Applicant and all Affiliated Companies, Domestic or Foreign:

2.	
PO Address:		

3.	
Corporation	
Partnership	
Individual	

4.	
COMPANY INFORMATION			

Name Of Entity	
Description Of Operations	
Area Of Activity	Years in
Business	

				

				

5.	OPERATION REVENUES AND PAYROLLS

Operation or Entity	Estimated
Gross Revenue	
Estimated Payroll	Number Of
Employees	

				

				

NON-MARINE  EXPOSURES

6.	List all premises OWNED AND/OR OCCUPIED by the Applicant with value in excess of $25,000:

Description	
% Occupied	
Estimated Value	
80% Building Fire Rate	

				

Bumbershoot  Policy  Application 	

7.	Personal Property in Applicant's Care, Custody or Control where values exceed $25,000:

8.	Contractual Liability
Give details of written agreements other than those automatically covered by M&C policy:

9.	Products Liability

LIST PRODUCTS:	LIST ESTIMATED
ANNUAL SALES	

Manufactured			

Sold			

Distributed			

10:	Professional Liability/Malpractice
Give details of any activities which might involve malpractice and/or errors and omissions exposures:

11.	Railroad Operations

Give details of any railroads owned, maintained or operated by Applicant:

12.	Automobile Exposure

	How Many	Operating Radius	Cargo Carried	

Private Passenger				

Light Trucks (Pickups)				

Medium Trucks				

Heavy Trucks				

X Heavy Trucks				

Tractors				

Vans (Passenger)				

Buses				

Automobile Losses (Please provice details on all losses above $100,000)	

YEAR	
POLICY TERM	
CLAIM COUNT	
TOTAL INCURRED GROUND UP	
VALUATION DATE	

Current Year					

1st Yr. Prior					

2nd Yr. Prior					

3rd Yr. Prior					

4th Yr. Prior					

List the number and type of other vehicles not licensed for public road use (earthmovers, bulldozers, cranes, etc.):

Type of Vehicle	How Many	

		

13.	Workers Compensation				
	Is Statutory Workers' Compensation carried?		Yes	No	
	If not, is Applicant a qualified self-Insurer?		Yes	No	
	Is any Excess Workers' Compensation Insurance Carried?		Yes	No	
	What is Employer's Liability Limit:	Each Accident			
 	Disease-Policy Limit
 	Disease-Each Employee

14.	Aircraft Exposure
Describe  owned  aircraft:	 	

Describe leased or chartered aircraft:

15.	Advertising Exposure
Describe methods and expenditures:

Is an advertising agency used?	Yes	No

16.	Does Applicant do any blasting or use explosives?

NON-MARINE LIABILITY LOSSES 	Five Year History

Date of Loss	Description	Paid	Outstanding	

				

MARINE EXPOSURES

17.	List below any landing, pier or wharf leased or operated by the Applicant where non-owned vessels come under the care, custody or control of the applicant:

Location	Estimated
Annual
Vessel Day(s)	
River and Mile
Marker	
Estimated Gross Receipts	

				

18.	Describe below any marine terminal or stevedore operation of the Applicant:

Location	River and
Mile Marker	
Gross Receipts	

			

19.	Describe below any shipbuilding, ship repairing, or barge cleaning operation of the Applicant:

Location	Type of Operation	Gross Receipts	

			

20.	Does the Applicant engage in any gas freeing?	Yes	No
If yes, describe:

21.	Does the Applicant ever charter or lease vessels?	Yes	No
If yes, describe:

22.	Does the Applicant own, operate or charter any private pleasure craft?

Yes	No	If yes, describe:

23.	Does the Applicant have exposure under the Longshoreman's and Harbor Workers' Act?

 	Yes	 	No	If yes, describe:	 	

Number Of Employees	
Payroll, If Any	
Type of Work Performed	

			

24.	Schedule all commercial vessels the Applicant owns, leases, charters or operates:

Name	Type of
Vessel	# of
Crew	PRIMARY LIMITS	
			Hull Value	P & I	Coll. Towers	

						

If more room is needed, continue on reverse side.

MARINE LIABILITY LOSSES 	(Five Year History, Over $5,000)

Date of Loss	Description	Paid	Outstanding	

				

If more room is needed, continue on reverse side.

BUMBERSHOOT/EXCESS LIABILITIES APPLICATION
MARINA OPERATORS SUPPLEMENT  (OPTIONAL)

RECEIPTS FROM OPERATIONS

BOAT STORAGE		
RESTAURANT		

BOAT REPAIR		
LIQUOR SALES		

MOORING/SLIPS		
STORE SALES		

HAULING/LAUNCHING		
BOAT RENTAL		

BOAT SALES		
BOATING INSTRUCTION		

FUELING		
JET SKI RENTAL		

OPERATION EXPOSURES

NO. BLDGS. USED FOR BOAT STORAGE		

MAX. NO. BOATS STORED IN ONE BLDG.		

AVG. VALUE ANY ONE STORED BOAT		

NO. MOORINGS/SLIPS AVAILABLE		

AVG. VALUE ANY ONE BOAT IN SLIPS OR MOORINGS		

MAX. NO. SLIPS ANY ONE FINGER PIER		

TYPE OF REPAIR WORK DONE		

DESCRIBE BOATS SOLD		

ADDITIONAL EXPOSURES (CHECK IF APPLICABLE)

SALVAGE OPERATIONS		
HOTEL/MOTEL/RENTAL	
	
BOAT BUILDING		
SWIMMING POOL	
	
SPONSORED RACES		
OTHER (DESCRIBE)	

SCHEDULE OF UNDERLYING INSURANCE

List all Liability and Compensation Policies to apply as Underlying Insurance

Type of Insurance	Insurance Company	Policy Period	Limits	Premium

General Liability
Products Liability / Compl. Operations

Automobile Liability

Workers' Comp

Other (Specify)

NOTE:  Minimum requirement is $1,000,000 CSL and GL including Products and Auto
MARINE EXPOSURES

Hull & Machinery

Protection & Indemnity

Collision & Towers

Barge Bailee	*

Ship Repairers	*

Pollution (OPA 90)

MOLL	*

* Rate if M & D

Other (Specify)

Do above policies apply to all companies or operations?	Yes	No

Has any coverage listed above been cancelled or renewal refused within the last five years?

 	 Yes	 	 No

If yes, state each coverage and the reason for cancellation or non-renewal:

Self-Insured Retention Limits Required:		$25,000	$50,000	Other $ Limit of Liability Required:  $ 	

Proposed Effective Date:   	

I/We hereby warrant that the information provided above is complete and accurate to the best of my/our knowledge and belief, and it is our understanding that underwriters shall rely upon the information and representations listed above heavily in determining the acceptability and rates and conditions of coverage. It is further understood that any misrepresentation  or omission may constitute grounds for immediate cancellation and denial of claims, if any.

It is further understood that this application shall be attached and form part of the policy, should one be issued.

Assured	 		

Title	

Date	

Submitting Broker