Marine Professional Negligence Insurance

Contact Information

Contact Name

Address

City

State

Zip/Postal Code

Country

Phone Number

Email

Company Website

Position

Company and Personnel Information

How long has your company been in operation?

Please provide the names and addresses of any subsidiary, affiliated or associated companies which you wish to include in the insurance:

Please describe the services you provide to your customers that you wish to be insured:

Please list your directors or partners, noting their professional qualifications or experience:
Name Qualification Years of Experience

Please provide the following information regarding the company's personnel:
Number of Managerial or Qualified Staff
Number of Clerical Staff
Number of Manual Workers
Total Number of Employees
**It may be necessary to provide us with resumes of key personnel

Please detail names of any trade associations to which you are affiliated or are members:

Have you obtained quality assurance accreditation from any internationally recognised organisation?
Yes No
If yes, please specify:

Please provide the following Annual Gross Income information (please specify currency, e.g. USD):
Annual Gross Income (last financial year)
Annual Gross Income (this financial year)
Annual Gross Income (estimated for next financial year)

Your Services

Please estimate this year's annual income that relates to:
Service % Further Information
Chartering Broking Which are your main markets?
S&P Broking
Ship Management
Ship Agency for Liner Principals Who are your main principals?
Ship Agency for Tramp Principals Who are your regular principals?
Freight Forwarding
Bunker Broking
Marine Surveying Percentage relating to yacht surveys:
Do you issue any guarantee surveys?
Naval Architect Please provide a description of the type of work you have undertaken and your areas of expertise:
Marine Consultancy What is the largest fee you have received from a single customer?
Stevedoring where you do not act as agent for the principal Estimated annual turnover:
Estimated sub-contracted (%):
Estimated tonnages handled (TEUs, Breakbulk, Bulk, Other):
Marine Engineering Largest fee from a single customer:
Ship Registry
Acting for Insurers e.g. Lloyd's Agent, P&I Club Correspondent Please describe:
Other Marine-Related Services Please describe:

Claims History

In the last five years have you had any of the following claims made against you?
Type of Claim Yes / No (If Yes, please provide full details)
Professional Liability or Errors and Omissions
Third General Party Liability
Cargo, Pollution or Statutory Liability

Have there been any circumstances that could have resulted in any of the above liability claims being made against you? If yes, please provide full details:
Type of Claim Yes / No (If Yes, please provide full details)
Professional Liability or Errors and Omissions
Third General Party Liability
Cargo, Pollution or Statutory Liability

Current Insurance

Are you currently insured for your professional negligence exposure?
Yes No

Do you require a specific deduction and / or limit of liability to be quoted?

Trading Conditions

Do you have any standard trading conditions or contracts?
Yes No
If yes, please provide a copy.

Are all customers advised of your standard conditions before services are provided?
Yes No

Other Information

Has any insurer ever declined to insure you, cancelled your insurance, refused to renew your insurance, or imposed special terms?
Yes No
If yes, please provide full 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.