Applicant's Name:

Mailing Address Line 1:

Mailing Address Line 2:

Phone Number:

Number of years in business:

Number of years under current management:

Location(s):

Maximum draft of vessels calling:

Water depth:

Number of berths:

Distance to next dock (Upstream):

Distance to next dock (Downstream):

Distance to nearest bridge or lock (Upstream):

Distance to nearest bridge or lock (Downstream):

Type of vessels handled (indicate number per year):

• Ocean Vessels (Dry Cargo):

• Ocean Vessels (Tankers):

• Barges (Dry Cargo):

• Barges (Tankers):

• Barges (Other):

Annual Number of Dockings last 5 years:

• Year:

• Amount:

• Year:

• Amount:

• Year:

• Amount:

• Year:

• Amount:

• Year:

• Amount:

Average value of vessels:

Average length of stay:

Are vessels inspected and signed for when picked up and delivered?

Vessels are moved by: HandPower WinchOther

Describe mooring facilities, including type of moorings:

Describe traffic passing to and from off your facility:

Who is responsible for mooring vessels at your facility?

Describe loading and unloading equipment including type, capacity and power:

Describe your procedures in the event of a breakaway:

Number of hours watchman is on duty:

Is clock punched?

Is facility lighted?

Is facility fenced?

Describe public access to the facility:

Are fueling services provided?

Types of fuel handled:

Who is responsible for bilge inspection and pumping if needed?

Is there a municipal or volunteer fire department?

What is the distance from the nearest fire fighting facility?

Number of fire hydrants at your facility?

Number of fire extinguishers at your facility?

• Number:

• Size:

• Kind:

Who is your current insurance carrier?

How long insured by them?

Has your insurance ever been cancelled?

If yes, why and by whom?

Limit of Liability requested $:

Limit of Deductible $:

If our quotation is accepted, what is the date of attachment?

Current Premiums (i.e. Minimum & Deposit and adjustment rate):

Are revenues generated from other than the marine operations described above?

If so, provide details:

List all losses during the last 5 years (amounts should include deductible, date of loss, amount paid, amount outstanding, and a description of the loss):