Please check coverage(s) applied for: 		
	Marine General Liability	
	Marina Operations Legal Liability	
	Protection & Indemnity	
	Workboat/Hull & Machinery	
	Mobile Equipment/Tools	
	Excess Liability	

MARINE BUSINESS OWNERS POLICY APPLICATION
(This application can be filled out electronically or by hand)

AGENT/BROKER ADDRESS:	

	

MAILING ADDRESS:	

	

PROPOSED EFFECTIVE DATES:

NAME INSURED/APPLICANT:	

	

LIST OF INSURED LOCATIONS:	

	
	
Describe Non-Marine Operation: ( if applicable)		

	  Check all operations that apply: 		
		Marina Operator	
		Marine Contractor	
		Shiprepairer/Marine Artisan	
		Other - Please explain	

TYPE OF COMPANY:	Corporation	Individual	Joint Venture	Partnership	

BUSINESS INFORMATION:	
1.	Gross Revenue for the Last Three Years:

2.	Estimated Revenue for Next Year:

3.	Of the Total Revenue, What % is Non-Marine?		

This application may be completed by your broker / agent. If you have insufficient space, attach a separate sheet.

SECTION I - MARINE GENERAL LIABILITY

1.	What % of work is subcontracted?

2.	Do your subcontractors carry Insurance?
3.	Do you have contracts extending your liabilities imposed by law?
4.	Does the applicant ever own/operate/charter any watercraft?
5.	Does the applicant have any storage exposure for care, custody, and control of Third Party property other than watercraft?
6.	Any exposure to flammables, chemicals, or explosives?
7.	Do you provide offshore work?
8.	Does the applicant lease equipment to others?
9.	Does the applicant lease any employees from or to others?
10.  Has the applicant's Marine Liability Insurance ever been cancelled or non-renewed?
11.  Do you have a history of violations and/or enforcement actions relative to work in tidal wetlands?
12.  Has the applicant and/or affiliated companies been involved with Bankruptcy proceedings?

Yes	No

DETAILS OF INSURANCE:	
Desired Policy Limits
Desired Policy Deductible
Please attach 3-5 years of loss history		
		
	, or if no losses, state “none”:	

SECTION IA - SHIPREPAIRER/MARNE ARTISAN SUPPLEMENTAL INFORMATION

Do you provide any of the below services:	Yes	No	
1.	Conversion/Re-conversion	
2.	Hot Work/Gas Freeing/ Fuel Line work on Gas/Oil Carriers	
3.	Underwater Work/Diving/Submarine Activities	
4.	Manufacturing of any product	
5.	Professional advise/services/consulting/Drawing Plans/Designs	
6.	Vessel Construction	

Breakdown of Revenue by (%) for type of work provided:	
1.	Boiler & Machinery %
2.	Hull %
3.	Electrical %
4.	Welding %
5.	Painting/Cleaning %
6.	Other %		

		

SECTION I A - SHIPREPAIRER/MARNE ARTISAN SUPPLEMENTAL INFORMATION (CON’T)

Breakdown of Revenue by (%) for type of vessel worked on:	
1.	Recreational Boats %
2.	Tugs & barges %
3.	Passenger vessels %
4.	Offshore supply vessels %
5.	Blue water vessels %		

		

SECTION I B - MARINE CONTRACTOR SUPPLEMENTAL INFORMATION

Do you provide any of the below services:	Yes	No	
1.	Gas Freeing/ Fuel Line Work on explosive carriers	
2.	Underwater work/Submarine activities/Diving work	
3.	Infrastructure work - Bridges/Tunnels/Roadways/Excavation/Earth Moving	
4.	Residential Construction	
5.	Pollution clean up	

Breakdown of Operation by (%) for type of work provided:	
1.	Pile Driving %
2.	Seawall construction %
3.	Bulkhead/Dock/ Breakwaters building & repair %
4.	Lift Installation %
5.	Carpentry %
6.	Salvage %
7.	Dredging %
8.	Jetty %
9.	Other %		

		

		

List your last Five Projects:

SECTION I C - MARINA OPERATORS SUPPLEMENTAL INFORMATION

Do you provide any of the below services:	Yes	No	
1.	Boat Storage	
2.	Social Club/Yacht Club	
3.	Restaurant/Bar	
4.	Public Access facility such as a Museum	
5.	Boat Shows	
6.	Boat Racing/ Recreational Boat Rental	

SECTION I C - MARINA OPERATORS SUPPLEMENTAL INFORMATION (CON’T)

Breakdown of Total Revenue by (%) for type of work provided:	
1.	Mooring/Slips %
2.	Maintenance / Repair %
3.	Hauling and Launching Services %
4.	Fuel Supply %
5.	Boat Storage %
6.	Boat Sales %
7.	Restaurant Sales%
8.	Liquor Sales%
9.	Store Sales%
10. Boat/Jet Ski Rental %
11. Boating Training/Instruction%		

		

		

		

What is the number of slips/moorings?
What is the average watercraft value in the slips?

Briefly describe the Fire Protection / Prevention in your facility:

Briefly describe the site's security:

SECTION II - HULL AND PROTECTION & INDEMNITY

Insurance Requirements:	
1.	Are quotes needed for Hull coverage?
2.	What is the Hull Operation Exposure?
3.	What is the Lay-up Period?
4.	What is the Navigation Area?
5.	What is the Trading Warranty?
6.	Are quotes needed for P&I Coverage?
7.	What is the P&I Limit Required?
8.	Does the applicant need Crew Coverage?
9.	What is the P&I Bodily Injury Deductible requested?
10.  What is the Crew Exposure?

11.  What is the applicant's Operations History?
12.  Has the Insured performed these or similar vessel operations for the past 5 years?
13.  Have there been any Hull Losses the Last 5 years?
14.  Have there been any P&I Losses including Crew Claims the Last 5 Years?

15.  Any Additional Info / Attachments please provide here:	Yes	No	

		
	Yes	No	
	Yes	No	
	Less than 3 Months
3 - 6 Months
6 - 9 Months
9 - 12 Months	
		
	Yes    No Yes    No Yes        No
Loss Runs                             Vessel Pictures Other Applications                          Expiring Surveys                                Policy	

SECTION II A- VESSEL SCHEDULE

Vessel Information:
(Please attach a separate schedule for multiple vessels.)	
1.	Named Vessel:
2.	Vessel Sub-Type:
3.	Vessel Type:
4.	Year of Build
5.	Hull Construction Material
6.	Length (ft.)
7.	Fuel Type
8.	Total Loss Only
9.	Insured Hull Value
10. Requested Deductible
11. P&I
12. Number of Crew
13. Attach Survey:
(If not available, please request and send)		

		

		
	Yes	No	
		
	Yes	No	
	
Yes	No	

SECTION III - CONTRACTOR'S EQUIPMENT

What Equipment is being covered?
Travel Lift Small tools Fork Lift
Cranes / Derricks
Trailors
Waterborn Equipment
Other

What is the Total Insured Value of the Equipment?
Please provide itemized equipment schedule ( valued in excess of 5,000 each)

What is the average age of the equipment in years?

What is the overall condition of the equipment?

Is there a Formal Maintenance Program for the Equipment?

Is the equipment adequately secured? (e.g. fenced and lighted area, anti-theft device, locked storage etc.)

Is there a daily safety evaluation of all equipment?

SECTION III - CONTRACTOR'S EQUIPMENT (CON’T)

What is the average number of years of experience and completeness of training records of the equipment operators?

What is the Loss Experience? (last three years)

How often the equipment used in hazardous operations?

Does the contractor have formalized site assessment program to address hazardous conditions?

SECTION IV - EXCESS LIABILITY

Does the applicant have in place any other Primary Insurances?

Does the applicant utilize subcontractors?

If so for what type of work and how often?

SECTION IV - EXCESS LIABILITY

Are all subcontractors required to name and waive the Insured and to provide certificates of Insurance?

Does the Insured have any non-marine Liability Losses? Please provide the record for the last 5 years.

Does the Insured own any vehicles?

Have there been any automobile liability losses?

I understand that the above information and supplemental information enclosed, which is correct to the best of my knowledge, is to be the basis of insurance if a policy is issued, but does not obligate the Applicant to accept the insurance nor oblige the insurer to effect insurance on the risk.

Applicant/Producer Signature	Date