Disbursements (Increased Value) Questionnaire

Name of Assured
Contact Name
Address
Telephone		Fax
Email
Website

Business Information

What is the nature of your business?

Vessel Details (if more than 10, or if it is more convenient, please email or fax these details):

Vessel#	Name of vessel	Type	DWT	GRT	Age	Value	IV Value	Flag	Class
1
2
3
4
5
6
7
8
9
10

Who owns the vessel(s)?
Who manages the vessel(s)?

Trading

Vessel#	Where is the vessel trading?	Regular liner trade or spot market?	Cargo - owned or third party?	What cargo / trade do you anticipate?
1
2
3
4
5
6
7
8
9
10

Experience

What experience does your company have in running these types of vessels?

Please provide CVs (email these separately to info@fp-marine.com)

Please provide crew information

Claims and Insurance

Have you got a claims record for your ownership / management ?

Yes No

If so, please provide the last 5 years' loss information

Losses*	Paid*	Outstanding	Deductible applied?
			Yes Amount No
			Yes Amount No
			Yes Amount No
			Yes Amount No
			Yes Amount No

Please provide details of your current insurers

Other Information

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

I confirm that this form has been completed accurately and that all material information has been given. Completion of this form is not binding by either party.

Company		Name
Date		Position