Marine Liability

Are you filling this out on behalf your client?*

YesNo

I am a(n)

Insurance BrokerReal Estate AgentLender / mortgage BrokerOther

Name*

First NameLast Name

Email*

example@example.com

Phone Number*

Area CodePhone Number

Business Type*

Name*

First NameLast Name

Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Is the Physical Address also the Mailing Address?*

YesNo

Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email*

example@example.com

Phone Number*

Area CodePhone Number

Business Name*

Gross Receipts*

Business Entity Type*

Type of Work Performed?

Type of Work Performed

Do any of the following apply to your business?

You have been in business for less than 12 months
25% of your annual gross receipts are derived from "non-marine" work
You build/repair/store other people's watercraft at any of the locations to be covered by this policy
You perform tank cleaning or gas-feeing operations
You do "hot work" on tankers, tank barges, or any similar vessels used for transporting oil, gasoline or explosive liquid or gas
You lease your employees to or from other employers
You perform work on offshore oil platforms
You perform diving operations
You repair/install lifeboats and/or life saving apparatus
You are presently under bankruptcy protection or have filed for bankruptcy in the last five (5) years

Do any of the following apply to your business?

You have been in business for less than 12 months
25% of you annual gross receipts are derived from "non-marine" work
You lease your employees to and from other employers
You perform diving operations
Your perform any blasting operations
You perform any tunneling
You perform and work for oil or gas
You install/repair underwater cables and/or pipelines
You are presently under bankruptcy protection or have filed bankruptcy in the past five years

YesNo

Any Liability Claims in the last 3 years?*

YesNo