Freight, Demurrage and Defence (FD&D)

Name of Insured
Contact Person
Main Address
Telephone		Fax
Email
Website

Vessel Details

Please provide the following information for each vessel

Vessel name	Name of Owner
Name of Technical Manager (if different from above)
Name of Operators - commercial management (if different from above)
Number and nationalities of crew (of each vessel)
Trading area
Expected cargoes
Gross tonnage
Built
Flag
Classification Society
Outstanding Conditions of Class, if any;
Vessel Type
IMO Number
Is the vessel under a charter or similar contract?		Yes No
If yes, please provide details.
Date of last main engine overhaul
Date of last special survey
Insured Value (USD)
Is the vessel used to carry passengers?		Yes No
If yes, please specify passenger capacity for which vessel is licensed.
Are passengers issued with a standard passenger ticket?		Yes No
If yes, please have a copy ready to send through when we contact you.
Are SOLAS 1994 Requirements (Section 3-6) being complied with?		Yes No
Has a Safety Management Certificate been issued?		Yes No
Has the vessel been subject to a P&I Condition Survey within the last 12 months?		Yes No
If yes, where, when and by whom was it carried out, and what recommendations were made?
Please give details of any change of Class over the past 3 years.

Claims Information

Please give details of your loss experience for the last 3 years.

Loss Experience for the last three (3) years (please send additional sheet if necessary)

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

Insurance Policies

Have you and / or any affiliated companies ever been denied coverage or been subject to cancellation by underwriters? If yes, please provide details
Please confirm whether or not you purchase Hull and Machinery insurance for the above vessels and state your current H&M policy terms
Does your Hull policy include the following?
a. 1/4 RDC	Yes No
b. 4/4 RDC	Yes No
c. No RDC	Yes No
d. Fixed and Floating objects	Yes No

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.

Name
Date
Company
Position