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Marine Contractors Application
Applicant Information
Name of Applicant:
Mailing Address:
Physical Address, If Different:
Inspection Contact Name
Yrs In Business Under Present Ownership:
Effective Date of Coverage:
Phone Number:
Email Address (Required)
*
Website:
Coverage Being Applied For:
Check All that Apply:
Marine General Liability
Protection & Indemnity
Towers Liability
Misc. Tools
Equipment
Workboats
Property (Buildings)
Workers Compensation
Other
Additional Coverage's we should Reach out about:
Property / Buildings
Commercial Auto
Workers Comp
USL&H
General Information:
# of Locations:
1
2
3
4
5
Address: Location 1
Security
Flood Lights
Fully Fenced
Chained
Watchman
Monitored Alarm
Security Cameras
Address: Location 2
Security
Flood Lights
Fully Fenced
Chained
Watchman
Monitored Alarm
Security Cameras
Address: Location 3
Security
Flood Lights
Fully Fenced
Chained
Watchman
Monitored Alarm
Security Cameras
Address: Location 4
Security
Flood Lights
Fully Fenced
Chained
Watchman
Monitored Alarm
Security Cameras
Address Location 5
Security
Flood Lights
Fully Fenced
Chained
Watchman
Monitored Alarm
Security Cameras
Have There Been ANY Losses in the Last 5 Years:
Yes
No
Please Descibe All Losses: Date / Event / Amount / Open or Closed
Measures Established to prevent future claims
Present Insurance Carrier:
Marine General Liablity
Description of Marine Operations:
Description of Non-Marine Operations:
Describe Exposure to Flammables:
Limits Desired:
$500,000
$1,000,000
Do You Need Excess Liability:
Yes
No
Excess Limit (In Addition to Primary):
$1M
$2M
$3M
$4M
$5M
Types of Operations (Check all that apply):
Pile Driving
Sea Wall Construction
Jetty Construction
Dock Building / Repair
Salvage Operations
Dredging Operations
Tow Operations
Other
Non-Marine Work
Describe Other Work:
Pile Driving Receipts:
Sea Wall Receipts:
Jetty Construction Receipts:
Dock Building / Repair Receipts:
Salvage Receipts:
Dredging Receipts:
Tow Receipts:
Other Receipts:
Non-Marine Receipts:
Any Blasting?
Yes
No
Explosive Storage?
Yes
No
Excavation / Earth Moving?
Yes
No
Bridge Work?
Yes
No
Draw Plans for Others?
Yes
No
Lease Equipment?
Yes
No
Lease Employees?
Yes
No
Use Subcontractors?
Yes
No
Formal Safety Program?
Yes
No
Tunneling / Earth Moving - Frequency
Bridge Work - Frequency & Type
Drawing Plans - Frequency & Type
Leasing Equipment - Frequency & Type
Leased Equipment with An Operator
Yes
No
Leasing Employees - Frequency & Type
Subcontractors - % & Type of work sub'd
Do you Get Sub's Insurance
Yes
No
Do you require Subs Carry $1M Liability
Yes
No
Do you require Subs to have Work Comp
Yes
No
Protection & Indemnity
# Owned Vessels
None
1
2
3
4
5+
# of Crew:
1
2
3
4
5+
Any Leased Vessels:
Yes
No
Limit Desired:
$1M
$2M
$3M
$4M
$5M
+$5M
Any Carry Passengers:
No
Yes
Do they Lay Up:
No
Yes
Lay-up Dates (To: From)
Navigational Area:
Boat 1 - Year
Length:
Manufacturer:
HP:
Value:
Boat 2 Year:
Length:
Manufacturer:
HP:
Value:
Boat 3 Year:
Length:
Manufacturer:
HP:
Value:
Boat 4 Year:
Length:
Manufacturer:
HP:
Value:
Boat 5 Year:
Length:
Manufacturer:
HP:
Value:
Mobile Equipment
Number of Pieces of Equipment:
1
2
3
4
5
6+
Equipment used off Premise?
Yes
No
What Purpose is it used for
Year:
Manufacturer & Model:
Value:
Year:
Manufacturer & Model:
Value:
Year:
Manufacturer & Model:
Value:
Year:
Manufacturer & Model:
Value:
Year:
Manufacturer & Model:
Value:
Year:
Manufacturer & Model:
Value:
We Will email you a schedule form for additional equipment
Tools:
Value of Tools (Employer Owned):
Maximum Value any 1 tool:
Towing Questionnaire
Number of Vessels Engaged in Tow Operations:
1
2
3
4
5+
Experience of Towers:
None
1-2 Years
3-5 Years
6-10 Years
Over 10 Years
Number of Crew (Incl Captain)
1
2
3
4
5+
Captains - Losses:
Yes
No
Describe All Losses (Date, Event, Amount):
Year Make & Model of Towing Vessel:
Year Make & Model of Towing Vessel:
Year Make & Model of Towing Vessel:
Year Make & Model of Towing Vessel:
Year Make & Model of Towing Vessel:
Make & Size of Vessels being towed:
Material, Length, & Diameter of Tow Line:
Maximum Speed of Tows
Will Engines be up or down:
Navigation Requested:
How often are vessels Towed:
Any Additional measures taken:
Property Applications will be emailed over.
Workers Comp Applications will be emailed over
Other Work
Please Describe Other Work in Detail
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