Application for Ship Repairer's Legal Liability Insurance Questionnaire

Name of Applicant

Address of Applicant

City

State/Province

Zip/Postal Code

Country

Phone Number

Fax Number

Email

Address(es) of Ship Repair Yard(s)

1. Number of years in ship repair business under present management

2. Number of Employees Full-time      Part-time  

3. Please provide brief information about the number of years' ship repairing experience of principals and senior operation personnel:

Name Number of Years Experience Other Information

4. Percentage of annual ship repairing gross receipts generated by repair of vessels with hulls made of:

Steel (%) Wood (%)   Other (please specify material and %)) Material %

5. Type of Work Performed:

Hull (non-"Hot Work") Engine
Welding / Burning / "Hot Work" Boiler
Painting / Scraping / Sand Electrical
Other  

6. Do you do ship conversion / reconstruction work?  Yes  No

7. Please provide the following information for each type of vessel worked on:

Type of Vessel No. of Vessels Worked on Average / Maximum Vessel Value USD* % of Annual GR Generated by Work on Each Vessel Type
*Please state length and GRT if values not known

8. Number of Vessels in Yard at any one time:

Yard Location Average Number of Vessels in Yard Maximum Number of Vessels Yard can Accommodate

9. Are any vessels repaired under the cover of a repair shed or other shelter?  Yes  No

If "yes", what is the published fire and EC rate?

10. Do you employ or subcontract in divers to do work underwater?  Yes  No

If "yes", how often?

11. Do you ever work on navy vessels involving the firing or testing of weapons systems?  Yes  No

12. Does your work ever involve lifting and / or moving vessels using cranes,hoists, etc.?  Yes  No

If "yes", how many times per year?   Lifting capacity of each crane?  

13. Are gas-freeing operations performed at your yard(s)?  Yes  No

If "yes", do your own employees or outsiders perform gas-freeing certification work?

14. If your own employees undertake the gas-freeing work, please provide the following information:

Employee Name Professional Qualifications Experience

15. How many gas-freeings are done annually?  

16. Within how many miles of the yard are the following operations performed?

Vessel Tests / Trials
 
Vessel movements in connection with repair operations (such as from one repair pier to another)

17. Describe the nature of any repairs carried out away from the yard and the percentage of total annual shipping gross receipts these account for:

Nature of repair % of total annual shiprepairing gross receipts

18. Do you do any work on vessels that is not repair, reconstruction or conversion work?  Yes  No

If "yes", please describe the nature of such work and the value of gross receipts it generates:

Nature of work Value of gross receipts (please specify currency)

19. Fire Safety

How close is the nearest public fire department station? (in kilometres)

Are the employees of the public fire department paid or volunteers?  Paid  Volunteers

Please state the number of fire hydrants and their proximity to your yard:


Please describe fully all fire protection facilities available, including the number of handheld fire extinguishers and the nature of any sprinkler system


20. Is the yard fenced?  Fenced  Not fenced

Please describe the nature of security measures, including watchmen:


21. Please enclose copies of any property and / or liability insurance surveys done at your yard within the past 18 months plus diagrams or maps of the yard layout.

22. Please enclose a copy of the yard's safety and procedural manual

23. Please note what percentage (%) of your total ship repairing gross receipts from work:

Subcontracted in   Subcontracted out  

24. Please provide details of your annual gross receipts for the last five years

Year Annual Gross Receipts

25. Estimated gross receipts for the next 12 months

26. Please provide details of all ship repairing losses, insured or not, for the last 5 years:

Date of Loss Amount of loss before application on any deductible Status of loss (i.e. if paid or reserved) Brief Description of Circumstances Surrounding Loss

27. Limit of Liability Required

28. Current Insurer

29. Current Insurance Broker

30. Has any insurer ever cancelled or refused to renew your insurance?  Yes  No

If "yes", please explain:


31. When does your current insurance expire? (dd/mm/yyyy)

I understand that the above information and supplemental information enclosed, which is correct to the best of my knowledge, is to be the basis of insurance if a policy is issued, but does not obligate me to accept the insurance nor oblige the insurer to effect insurance on the risk

Name   Date