Marine Commercial Liability
Supplementary Information For Vessel Construction

Applicant's Name:

Mailing Address Line 1:

Mailing Address Line 2:

If accepted by the Company, coverage is desired beginning

Location of yard(s):

• Location (a):

• Location (b):

• Location (c):

• Location (d):

Type of vessels built and Materials used.

Deck Barges: SteelWoodAlum.FiberglassOther

Number of Deck Barges built Annually

Crane Barges: SteelWoodAlum.FiberglassOther

Number of Crane Barges built Annually

Tank Barges: SteelWoodAlum.FiberglassOther

Number of Tank Barges built Annually

Hopper Barges: SteelWoodAlum.FiberglassOther

Number of Hopper Barges built Annually

Towboats: SteelWoodAlum.FiberglassOther

Number of Towboats built Annually

Crewboats: SteelWoodAlum.FiberglassOther

Number of Crewboats built Annually

Supply Boats: SteelWoodAlum.FiberglassOther

Number of Supply built Annually

Fishing Vessels: SteelWoodAlum.FiberglassOther

Number of Fishing Vessels built Annually

Private/Pleasure (Type): SteelWoodAlum.FiberglassOther

Number of Private/Pleasure (Type) built Annually

Other: SteelWoodAlum.FiberglassOther

Number of Other built Annually

Describe method of launch:

Describe extent of trials (hours of trial operation, number of crew, usual number of others aboard):

Describe delivery trips (distance, number of crew, others aboard, tower or land conveyance):

	Usual Construction Period (months)	Average Contract Value	Maximum Contract Value
Deck Barges
Crane Barges
Tank Barges
Hopper Barges
Towboats
Crewboats
Supply Boats
Fishing Vessels
Private/Pleasure
Other

Maximum contract values at any one yard location

IF APPLICATION IS FOR COVERAGE ON ONE SPECIFIC VESSEL, complete this item:

(a) Type of vessel

(b) Dimensions

(c) Hull Materials

(d) Completed Contract Price

(e) Period of Construction: From to

(f) See item 1 above construction site (check) (a)(b)(c)(d)

Describe extent of trials:

Delivery description and location:

Fire Protection:

Public fire department PaidVolunteer

Distance to nearest fire department

Public fire hydrants: How many?

Public fire hydrants: How far distant?

Public fire mains: Size? Pressure?

Private fire protection (describe):

Building fire protection (describe):

Watchmen:

How many watchmen employed?

How many watchmen on each shift?

Watchclocks? YesNo

Is yard fenced? YesNo

Is guard at gate when operating? YesNo

Describe applicant's experience as builder:

Applicant's gross receipts for past 5 years derived from vessel construction

Amount	Year

Percentage of repair work sub-contracted

Is sub-contracted work accompanied by a hold harmless/indemnity agreement?

Waiver of subrogation?

Are certificates of insurance required?

What limits?

Does the applicant enter into contractual agreements other than those normal to the industry?

If so, provide details and copies of contracts:

Current insurance carrier:

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

Limit of liability and deductible requested:

Has any policy or coverage been declined or non-renewed during the past five years?

If so, provide details:

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

If so, provide details:

Does applicant use employee leasing services and/or temporary workers?

If so, are there hold harmless/indemnity agreements in place in the applicant's favor?

Waiver of subrogation?

Are certificates of insurance obtained?

What limits?

Contact and phone number to arrange an inspection:

LOSS EXPERIENCE (past 5 years) including any insured losses. Show all losses gross (before application of deductible, if any):

Date of Loss	Description	Amount (Gross)

Are vessels under construction financed?

If yes, with whom

Current line of credit $

REMARKS (Please use this space to comment upon facts not brought out in answering application items above - i.e. Emergency procedure, Loss Control, OSHA compliance, plans for expansion or upgrading of facilities, etc.)