Protection and Indemnity Insurance

Protection and Indemnity Insurance Application Form

Name of Insured


Contact Person


Main Address


Telephone


Fax


Email


Website


Vessel Details
Please provide the following information for each vessel

Vessel name


Name of Owner

Name of Technical Manager (if different from above)

Name of Operators - commercial management (if different from above)


Number and nationalities of crew (of each vessel)


Trading area


Expected cargoes


Gross tonnage


Built


Flag


Classification Society


Outstanding Conditions of Class, if any;


Vessel Type


IMO Number

Is the vessel under a charter or similar contract? Yes No
If yes, please provide details.

Date of last main engine overhaul


Date of last special survey


Insured Value (USD)

Is the vessel used to carry passengers? Yes No
If yes, please specify passenger capacity for which vessel is licensed.
Are passengers issued with a standard passenger ticket? Yes No
If yes, please have a copy ready to send through when we contact you.

Are SOLAS 1994 Requirements (Section 3-6) being complied with?
Yes No

Has a Safety Management Certificate been issued?
Yes No

Has the vessel been subject to a P&I Condition Survey within the last 12 months?
Yes No
If yes, where, when and by whom was it carried out, and what recommendations were made?
Please give details of any change of Class over the past 3 years.

Claims Information
Please give details of your loss experience for the last 3 years.

Loss Experience for the last three (3) years (please send additional sheet if necessary)
Losses* Paid* Outstanding Deductible applied?
Yes Amount No
Yes Amount No
Yes Amount No
Yes Amount No
Yes Amount No

Insurance Policies
Have you and / or any affiliated companies ever been denied coverage or been subject to cancellation by underwriters? If yes, please provide details
Please confirm whether or not you purchase Hull and Machinery insurance for the above vessels and state your current H&M policy terms
Does your Hull policy include the following?
a. 1/4 RDC Yes No
b. 4/4 RDC Yes No
c. No RDC Yes No
d. Fixed and Floating objects Yes No

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.

Name


Date


Company


Position