"Protection and Indemnity Proposal Form - Maritime International Solutions (Insurance Brokers) Limited"

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Download "Protection and Indemnity Proposal Form - Maritime International Solutions (Insurance Brokers) Limited"

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PROTECTION & INDEMNITY
PROPOSAL FORM
Owner(s):
Manager(s):
Address:
Telephone:
Fax:
Email:
Manager:
Address:
Telephone:
Fax:
Email:
Mortgagee:
Value of
Vessel:
Address:
Period:
/
/
To:
/ /
PROTECTION & INDEMNITY
PROPOSAL FORM
Owner(s):
Manager(s):
Address:
Telephone:
Fax:
Email:
Manager:
Address:
Telephone:
Fax:
Email:
Mortgagee:
Value of
Vessel:
Address:
Period:
/
/
To:
/ /
PROTECTION & INDEMNITY
PROPOSAL FORM
Vessel Name: (ex)
GT/DWT
Year Built
Flag
Class
ISM/IMO
Status
Trading Area:
Date Of Last Condition
(
/
/
)
Outstanding Defects:
YES / NO
Survey:
If yes, please provide a copy of Last P&I Club
Survey
Number of Officers & Crew:
Officers:
Crew:
Nationality of Officers & Crew:
Officers:
Crew:
Limit of Liability:
Deductibles:
Crew any one accident or occurrence:
Cargo any one claim:
Constructive Total Loss:
1/4
th
R.D.C:
Additional 3/4
th
R.D.C:
All other:
Claims on Vessel in last 5 years (whether insured or not)
Year
Claim Amount
Claim Details
PROTECTION & INDEMNITY
PROPOSAL FORM
Claims cont..
Year
Claim Amount
Claim Details
Details of
previous
Insurances:
Previous Insurance - In respect of this, or any other vessel owned or commanded by you, has
any Insurer:
(a)
Declined cover
Yes:
No:
(b)
Cancelled or declined to renew cover
Yes:
No:
(c)
Imposed loadings, restricted terms or
Yes:
No:
additional premiums
If yes, please give details:-
Disclosure of Material Facts
You must disclose all material facts, not only those covered by specific questions in this Form.
Material facts are those which an insurer would regard as likely to influence the acceptance and
assessment of your application. A good example is claims experience. If you fail to disclose a
material fact, your insurance cover could become completely void. If you are in doubt as to
whether any fact is material, you should disclose it.
Signed:………………………
Capacity: (i.e. Director etc):……………………….
Date:……………………
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