APPLICATION FOR SHIP REPAIRERS LEGAL LIABILITY INSURANCE

APPLICATION FOR SHIP REPAIRERS LEGAL LIABILITY INSURANCE

Please complete all sections below to apply for ship repairer coverage. All information is required for processing.
Applicant Name*
Mailing Address
Total Projected Gross Receipts for Terms ($)
Proposed Expiration Date

MonthDayYear
Date
List of Insured Locations - Location 1
List of Insured Locations - Location 2
Type of Work Performed:
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
Other (describe)
Operations
If fiberglass/painting, is all painting/fiberglass work in a UL approved booth or outdoors in the open?
Are all operations 100% mobile?*
If not 100% mobile, are all non-owned boats on applicant’s premises secured in completely fenced area or kept indoors?
Does the account perform any modifications over stock?
Any work done to vessels over 60 feet in length?
Any work done to vessels valued over $1,000,000?
Does the applicant have at least 3 years’ experience in this trade?*
If diesel engine repair, does the applicant have diesel certifications from the different manufacturers?
Does applicant work on vessels from scaffolding?
Underwriting
Has the applicant experienced any losses (covered or uncovered) in the previous 5 years?*
Does the applicant perform any non-marine work?
Does the applicant perform any diving operations?
Does the applicant perform any gas freeing?
Does the account refurbish any propellers?
Does the applicant use any subcontracted work where the subcontractor does not carry $1M of ship repairer’s legal liability?
Inspection Contact and Phone Number*
Applicant Signature*
Applicant Signature Date*

MonthDayYear
Date
Agent or Broker Signature*
Agent or Broker Date*

MonthDayYear
Date
ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO CIVIL FINES AND CRIMINAL PENALTIES.
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APPLICATION FOR SHIP REPAIRERS LEGAL LIABILITY INSURANCE

Type of Work Performed:

Operations

Underwriting