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Personal Professional Indemnity and Legal Expenses Insurance For Designated Persons and Shore-based Employees

Please complete the table below EITHER for a named insured policy (Option A) OR to apply for cover for "any shore-based employee who is, or shall become, a director, officer or other shore-based manager or supervisor of the company" (Option B) and then complete all further sections.

General Information

Contact Name
Address
City		State/Province		Zip/Postal Code
Country
Phone Number		Email

Option A - A Named Insured Policy

Name(s) of proposed insured(s) and their contact address	Please provide brief details of their position, qualifications and experience

Option B - Any shore-based employee who is, or shall become, a director, officer or other shore-based manager or supervisor of the company

Company name and address:	Please advise: Number of Directors Number of senior managers and superintendents TOTAL NUMBER

Please Complete the Following

Name of Vessels assigned to the DP or operated by the company employing the proposed insureds	Please provide details of the vessels' type and age:

Has any of the proposed insureds ever been personally involved in an incident where a third party has claimed or alleged professional negligence? If yes, please provide details.

Does the company employing the proposed insured(s) purchase ship manager's professional indemnity insurance?

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.

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.