Insurance Marine Application Form

MARINE INSURANCE APPLICATION FORM

Applicant / Insured Information

Date of Birth (if individual):   Tax or Employer ID (if applicable):

Vessel / Risk Details

Navigation Limits (describe waters where vessel will operate):   Usual Use / Trade:

Policy Coverage & Requested Limits

Requested Policy Type(s) (check all applicable):
Hull & Machinery Protection & Indemnity (P&I) Cargo Freight War & Strikes (if requested)

Proposed Policy Period From: To:

Optional Endorsements / Additional Coverage

Optional coverage / endorsements (select as required):
Sue and Labour Expenses Salvage & Wreck Removal General Average Pollution Liability

Previous Claims / Loss History

Have you sustained any marine losses, claims, or cancellations in the past five years?  Yes No

Additional Interests / Mortgagees / Beneficiaries

Name of additional interest or mortgagee:

Interest / Relationship:   Cover Percentage:

Warranties, Representations and Exclusions

The applicant warrants that the information provided in this application is true and complete to the best of the applicant's knowledge. Any material misrepresentation, concealment, or omission of fact shall entitle the insurer to void the policy ab initio or deny coverage as permitted by applicable law. The applicant agrees to notify the insurer promptly of any material change in the risk or vessel condition prior to binding coverage.

Standard exclusions typically apply, including but not limited to: loss or expense caused by wilful misconduct of the insured; ordinary wear and tear; latent defects not discoverable by reasonable inspection; unseaworthiness at the time of the risk attaching where such unseaworthiness was known to the assured and not disclosed; war and strikes risks unless specifically endorsed; and pollution liabilities except where endorsed. The precise scope of coverage and exclusions will be governed by the policy wording issued by the insurer.

Inspection, Survey and Surveyor Access

The applicant authorizes the insurer and its appointed surveyors to inspect the vessel at reasonable times. Any survey reports or repair recommendations must be complied with as a condition precedent to binding or continuance of coverage where requested by the insurer. Failure to permit inspection or to effect recommended repairs may result in declination of coverage or imposition of additional terms.

Declaration and Signature

I declare that the information contained in this application and any attachments is true and complete. I understand that this application, together with any statements made in connection herewith, shall form the basis of any policy issued. I acknowledge that the insurer may rely on the representations made and that failure to disclose material facts may result in denial of coverage or rescission of the policy. I authorize the insurer to obtain and disclose underwriting and claim-related information as permitted by law.

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