Builder S Risk Insurance on Commercial and Private Pleasure Vessels Application

Hull and M

BUILDER’S RISK INSURANCE ON COMMERCIAL AND PRIVATE PLEASURE VESSELS APPLICATION

1. Please answer all questions. If any section does not apply, please indicate with “Not Applicable” OR “None”.
2. If there is insufficient space to complete your answer for a particular question please use and attach as many additional pages as required to include any supplementary information.

APPLICATION FORMS PART OF THE POLICY

The Applicant(s) submission of this application including any additional information does not obligate the Applicant to buy insurance nor are we obligated to sell or offer insurance upon any specific terms requested. If insurance is effected, this Applicant’s application, including any additional information provided, all will attach to and form part of the policy that is issued.

Completion of this form does not bind coverage. Applicant’s written acceptance of an insurance company’s quotation and company’s written agreement to be bound are required to bind coverage and issue policy.

1. Applicant

Applicant’s Name:

Street:
City: State/Province: Postal Code:
Website:
Telephone Number: ()-Proposed Effective Date(MM/DD/YY): / /
Number of Years in Business:
Nature of Business:
Loss Payable to:
Agent/Broker Name:

Annual Gross Receipts: $Annual Payroll: $
2. Construction
Type of Vessels and Materials Used:
Type of Work Performed:
Size of Vessels Constructed: Duration of Construction:
How are vessels launched after completion?
Type of Vessels Constructed Per Annum:
Total Values of Vessels Constructed Per Annum: $
Highest Valued Vessel Constructed: $
Location(s) of Work Being Performed:
Is there a Fence? □Yes □No
Other Security Measures:
3.Fire Protection

4.Claims History

LOSS EXPERIENCE OVER THE PREVIOUS FIVE (5) YEARS

* If there are no claims, please indicate NIL
Brief Details of Any Large Losses (If Any) :
5. Insurance Details
Limit of Liability Required: $
Is Protection and Indemnity Required? □Yes □NoIf yes, what limit? $
Are subcontractors employed? □Yes □No
Do subcontractors carry their own insurance? □Yes □No
If work is being performance inside, please provide details on the building (i.e. construction, sprinklers, etc.)
Is Applicant Currently Insured? □Yes □NoIf so, Name of Insurer:
Reason for Change:
Current Premium: $
Current Terms and Conditions:
Has Any Insurer Cancelled or Refused to Insure You? If Yes, State Name of Company and Provide Details:
Is there any other relevant information to influence special terms for consideration by Underwriters:
Signing this form does not bind the applicant or the company to complete the Insurance. But it is agreed that the information given herein shall be the basis of the contract, should a policy be issued.
N.B. – Application must be signed by the applicant.
Name of Applicant Applicant’s Signature
Name of BrokerDate

**A signed application is required upon binding **

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