MARINE PORTS & SHIPS SERVICE PROVIDER

PROPOSAL FORM

	CONFIDENTIAL




	Address



	VAT No.


	Telephone

	Fax

	Telex

	Insurance Broker to whom quotation should be sent

Page 1 of 4

1 General Information (if additional space is required please list separately)

a) Date established

b) Name and address of any Subsidiary, affiliated or associated companies which you wish to cover.

Name and Address		Principal Activity




c) Address of all branch offices to be included in the cover






d) No. of Directors/Partners		Total no. of staff engaged in providing Services listed in Question 2 e)


e) Names, positions, professional qualifications and number of years’ experience of Directors/Partners and Senior Managers





f) Name of person to whom correspondence should be addressed


g) Are you a Member of any Trade Association – please detail




2 Gross Annual Income (fee and commission earned)

a) Please indicate currency e.g. US$		b) Last financial year


c) Estimate for this financial year		d) Estimate for next financial year


		dd) Of which estimated income from UK operations (if applicable)

e) Please indicate the percentage of your Gross Annual Income from the following activities to be insured

Tramp Agent	%	Bunker Broker		%

Liner Agent	%	Ship Manager*		%

Chartering Broker	%	Freight Forwarder*		%

Sale & Purchase Broker	%	Forwarding Agent		%

Marine Surveyor	%

Representative of Insurance Interests
(e.g. P&I Clubs, Corporation of Lloyds, Classification Societies)				%

Other activities for which insurance is required (please specify)
				%
(Please also complete supplementary form*)

3 Principals

Please name the Principals for whom you regularly act



Do you have any financial interest in any of your principal’s companies?			Yes	No

Do your principals have any financial interest in your company?			Yes	No

4 Contract Conditions

a) Do you operate under Standard/National Contract Conditions?			Yes	No

b) Do you operate under your own Contract Conditions?			Yes	No

c) If “Yes” to either of the above, do you always advise your customers that Contract Conditions apply?			Yes	No

Please supply copies of all Contract Conditions under which you operate If “Yes” to (as) or (b) please give details on a separate sheet

5 Claims History

a) Have any claims been made against you, or have there been any circumstances likely to give rise to a claim being made against you in the last five years?			Yes	No

CONFIDENTIAL