Marine insurance

Insured

Insured*

Registration number*

Address

Telephone / Fax

email

Bank account (SWIFT)*

Person in charge*

Sole insured
Add co-insured

Insured*

Registration number*

Address

Telephone / Fax

email

Bank account (SWIFT)*

Person in charge*

Vessel information

Vessel name*

Vessel type*

IMO*

Year of built*

Please enter a value greater than or equal to 1890.

Shipyard

GT*

Please enter a value greater than or equal to 0.

Deadweight

Please enter a value greater than or equal to 0.

Flag*

Registry port

Classification society*

Last class inspection

d

m

y

Number of crew on board*

Please enter a value greater than or equal to 0.

Main engine

Auxiliary engines

Renovation

No renovation
Existing renovation

Date of renovation*

d

m

y

Please describe what was done*

Trading area

Legal information

Shipowner*

Operator / Manager*

Agent / broker

Premium payment

Shipowner will pay the premium
Operator will pay the premium
Broker will pay the premium

Beneficiary or mortgage

Statistics

Please specify exact number of casualties during the last five years*

Please enter a value greater than or equal to 0.

Casualty information*

Condition of cover

Period from*

d

m

y

Period till*

d

m

y

Terms and conditions*

Hull & Machinery and allied perils (including Yacht and Builder's)
Protection & Indemnity (including Blue Cards and crew liability)
Personal accident on board

Special instructions

Hull & Machinery and allied perils

Basic perils*

ITC Cl.280 or equivalent
ITC Cl.280 but free of particular average
ITC Cl.284 or equivalent
ITC Cl.289 or equivalent

Collision liability (Running down clause fixed and floating objects)*

Collision excluded
3/4 collision liability
4/4 collision liability

Additional perils

Increased value (ITC Cl.290)
War and Strikes (ITC Cl.281)
Loss of Freight
Piracy

Currency of contract*

Vessel Sum Insured*

Please enter a value greater than or equal to 0.

Suggested deductible

Increased value

Please enter a value greater than or equal to 0.

War and Strikes value

Please enter a value greater than or equal to 0.

Fraight (daily)

Please enter a value greater than or equal to 0.

LoH coverage (in days)

Please enter a value greater than or equal to 0.

LoH deductible

Please enter a value greater than or equal to 0.

Protection & Indemnity

Please specify requested perils*

Contract currency*

Aggregate limit*

Please enter a value greater than or equal to 0.

Personal accident on board

Basic perils*

Death
Permanent disability
Temporary disability

Contract currency*

Aggregate limit*

Please enter a value greater than or equal to 0.

Confirmation

Please leave your contact details here

email

It is hereby noted and agreed that this application form is filled in diligent and correct and any misrepresentation or faulse information provided may result in claim reimbursement will be rejected.

I confirm all information is correct