Commercial Vessel Application

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Business Owners Name

Business Address

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

Business Phone No*

Contact Name / Title

Contact Phone No

General Operating Information

Type of Operation

Navigation Area

Average No. Days/Trip:

Average No. Lay Days Between Trips

Are back to back trips undertaken?

Yes
No

Is Vessel(s) Navigated Year Round?

Yes
No

Off Season Port

Lay-up Period

Hull Information

Name of Vessel

Document No

Vessel Type/Rig

Hull Construction

Builder Name

Year Built

Hull Length Overall

Bream

Draft

Gross Tonnage

Home Port

Date Purchased

From

Price

Last Haul Out Date

Last Major Work Performed

Does Vessel Maintain a Stability Certificate?

Yes
No

Machinery Information

Main Engines

No

HP Each

Year Built

Manufacturer /Model No

Total Engine Hours (each):

Recent Overhaul:

Hours Since Last Overhaul

Reason for Overhaul

Other Engines

No

Purposes

Year Built

Manufacturer/Model No

Serial No(s)

Total Engine Hours (each):

Recent Overhaul

Hours Since Last Overhaul

Reason for Overhaul

Electronic Information

List type

Manufacturer

Model No

Serial No

Age

Crew Information

Name of Captain

First Last

Years of Experience

Date of Birth

Does Captain Own Interest in Vessel?

Yes
No

No. of Crew (Ex. Captain):

Full Time / Part Time

Does Captain or Crew have US Coast Guard License?

Yes
No

Name(s)

Can Crew be characterized as

Steady
Transient

Has Captain ever had a Hull and Machinery or P&I Claim on a Vessel under his command?

Yes
No

Explain

Insurance Information

Has Owner ever had any insurance canceled, non-renewed or declined for coverage?

Yes
No

Please identify Underwriter and reason

Does Owner own Vessels not presented to this Company for coverage?

Yes
No

Current Insurer

Expiration Date

Current Premiums

Hull

P&I

Other

Mortgage

Mortgage Balance

Loss Payee

Limits Desired

Hull

BOW

P&I

Loss Information:(List all Hull and Machinery and P&I Claims for last Five (5) years or all Vessels owned or operated by the Applicant including Vessels sold or lost)

Charter

Commercial Vessel Application

General Operating Information

Hull Information

Machinery Information

Main Engines

Other Engines

Electronic Information

Crew Information

Insurance Information

Mortgage