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Marine Liability Insurance Application


Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

Contact Inforamtion
First Name
Required
Last Name
Required
Mailing Address
Required
ZIP / Postal Code
Required
E-Mail Address
Required
Company Information
Name of applicant and all affiliated companies, domestic and foreign
Required
Additional Assureds to be covered
Required
Premises
List and describe all locations owned, rented, or controlled by the applicant ( state whether factory, warehouse, office, yards, terminals, etc.)
Required
State the intrest of the applicant in all occupied premises (owner, general lesee, or tenant). If jointly occupied identify the part occupied by the applicant.
Required
Does the applicant plan any structural alterations, construction or demolition operations at any location?
Required
Operations
Anual advertising expendature
Required
Annual Sales
Required
Gross Receipts
Required
Payroll
Required
No. of employees (excluding shipboard)
Required
No. of employees (including shipboard)
Required
Throughput (if applicable)
Required
No. of years in business
Required
Please describe the business operations
Required
Is applicant involved in the manufacture, distribution or installation of any products?
Required
Is the applicant engaged in any phase of nuclear energy or defense work?
Required
Does the applicant do any blasting or use explosives?
Required
Does the applicant store or use and explosive or hazardous substances on the premises?
Required
Does the applicant use mobile equipment?
Required
Liability Exposures
Provide details of any contractual liability agreement or general agency agreement
Required
Give number (if any) of any doctors, nurses, etc. and explain if the applicant operates a hospital
Required
Give details of any railroads owned, maintained, or operated by the applicant
Required
Does applicant have any exposures in the following? (check all that apply)
Optional


Please describe any watercraft whether owned or non owned that are used (vessel, year built, dimensions, GRT, no. of crew)
Required
List all media used in advertising and state whether an advertising agency is used
Required
Insurance Details
Give details of losses incurred in excess of $5,000, whether insured or not, over the past five years.
Required
Describe the largest claim made against the applicant (if any)
Required
List total losses paid during current policy period (indicate whether auto, general, products, other)
Required
List any other liability insurance carried by the applicant
Required
Please provide details if any specific limitations or exclusions in primary insurance.
Required
Insurance limits requested
Required
what is the requested attachment date?
Required
/ /
Submission Validation
Required
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Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.




 
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