Charterer's Liability Questionnaire

Contact Information

Contact Name

Address

City

State

Zip/Postal Code

Country

Phone Number

Email

Company Website

Position

Company Information

Address of subsidiaries:
Number of years in chartering business:

Please provide full loss record as charterers whilst acting in this trade and/or other chartering activities:

Date of loss Amount of loss* (before deductible) Status of loss (paid / reserved, etc) Brief description of circumstances surrounding loss

* Please specify currency here


Details of vessels anticipated taken on charter during the next 12 months:

Type / Class Age / Grt Flag

Number of vessels anticipated over the next 12 months:
  On voyage charter party:
  On round voyage charter party:
  On time charter party:

Describe the principal trading areas and / or voyage routes with estimated duration of voyages:

Principal Trading Areas / Voyage Routes Estimated Duration of Voyage

Please provide the following information regarding the cargo to be carried:

Type of Cargo Bulk / Bagged / Containerised / Other Full or Space Charter If Space, what %? Cargo owner or Third Party Ship's or Charterer's Liability

Who is responsible for employing Stevedores and loading and/or discharging under the terms of the Charter Parties?

What types of Charter Parties are used (please provide examples)?

Are any sub-charters involved? If yes, please supply copies of the agreements. Yes No

Will charterers have any benefit under:
  Shipowners Hull and Machinery insurance?
  Shipowners Protection and Indemnity entry?

Limit of liability required:

Limit of self-retention to be carried:

Please provide any other details of operation that may be relevant:

Other Information

Who are your current insurers?

Who are your current brokers?

What is your current premium?

Please provide any further information that may be material to the insurers:

Please provide the following:
Company Name
Date Position

Important Note: The questions contained in this form are designed to give insurers information regarding your business. It may not address every aspect and it is your duty to disclose all material information to insurers that may affect the premium or conditions.