Fire Protection

Public Fire Dept.: Paid or Volunteer______

Distance from yard______

No. of public fire hydrants_____ Distance from yard___

Private Fire Protection (describe in full)______

______

Watchman Service:

Is service provided? Yes No

How many 24 Hours per day: Yes No Watch Clock: Yes No

Is yard fenced: Yes No Guard at gate: Yes No

Describe adjacent exposures to the insured location:______

______

  1. Gross receipts for past 3 years:

$ 1998

$ 1999

$ 2000

$ Estimated for current year

Gross Receipts from Other work (work other than ship repair):

  1. Breakdown of repairs by the following types of work:

Hull repairs%Machinery%Hydraulics%

Welding%Electrical%Gas freeing%

Boiler%Painting% Other____%

If gas freeing operations are carried out, state number of vessels gas freed last year:______

Describe “Other Work”: ______

______

No. of vessels in No. of vessels repaired

repair yard last year: _____ outside the yard last year:

Average value of vessel:Maximum value of vessel:

Does the applicant:

employ a full-time gas free chemist: Yes No

employ an outside sub-contracted chemist: Yes No

Does the applicant strictly adhere to the rules & regulations of the national fire protection agency applicable to work on vessels which have carried combustible liquid in bulk, as fuel or cargo. Yes No

If No, please explain: ______

How many total employees: Total gross wages: How many employees are eligible: USL&H ______Jones Act:

Yard facilities

  1. # of Drydocks ___

Name / Year Built / Size / Capacity / Last Certification Date
  1. Marine Railways

Name / Year Built / Size / Capacity / Last Certification Date

5. Repair Piers

Name / Year Built / Size / Capacity / Last Certification Date

6. Travel Lifts or Hoists

Name / Year Built / Size / Capacity / Last Certification Date

7. Type of vessels worked on:

Military_% Commercial “Blue Water”%

MARAD ______%Commercial “Brown Water”%

Pleasure Craft% Cruise ship ______%

Other% Specify______

Do you require Dept. of Defense Endorsement? Yes No

8. List any contractual liability limitation agreements and attach copy of repair contract:

______

9. “Downstream” operations: Percentage of work performed away from the scheduled premises in other’s care, custody or control? ______%

Describe the “Downstream” work?______

Where is/will the “Downstream” work be performed?______

10. Detail owned, hired or leased watercraft, docks or floats used duringrepair operations:

VesselYear BuiltDimensions GRT

PLEASE ATTACH YOUR AUDITED FINANCIAL STATEMENT. FAILURE TO PROVIDE AN AUDITED FINANCIAL STATEMENT MAY RESULT IN A PREMIUM SURCHARGE.

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