Crew PA

Crew Personal Accident
The application form that follows is aimed to generate information regarding your operation’s exposure to risk and guide underwriters to provide the best package of cover and terms available. Please complete all relevant sections in full as accurately as possible as this may form a part of your future contract.
INSURED INFORMATION
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Email
example@example.com
VESSEL INFORMATION

Please provide the following information for all vessels

Loss Record
Please give details of all Accidents/Claims during the last five years:
I confirm that this form has been completed accurately and that all material information has been given. Completion of this form is not binding by either party.
Should be Empty:

Crew Personal Accident