Captains Form - Trysail Insurance Agency

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Company Name

Type of business

Business Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Business Web Address

Contact Name

Contact Phone

Contact Email

Year Business Established

Total Number of Employees

Type of Insurance Requested

When do you need Insurance Coverage by (Renewal Date)

Do you require coverage for your crew?

Do you require hull coverage?

Do you require Protection and Indemnity Coverage?

Captain

Current License(s) Held

License Number (s)

Years with Present License Grade

Date of License Expiration

License Tonnage

License Geographic Scope

Background Information

Previous Two Employers and Years Employed:

Employer:

Years Employed

Employer:

Years Employed

Do you own or have an ownership interest in any vessels?

Yes
No

Has your License ever been suspended or revoked?

Yes
No

Have you ever been convicted of a felony?

Yes
No

Have you ever had employment terminated by a maritime employer?

Yes
No

Have you ever been convicted of a DWI or DUI?

Yes
No

List all waters navigated:

List all associations or unions of which you are a member

List all the types of Vessels that you currently operate

Additional Information / Questions