PROPOSAL FORM

CONFIDENTIAL

Address

VAT No.

Telephone

Fax

Telex

Insurance Broker to whom quotation should be sent

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

b) Has any insurer:

i)   Declined to insure you?

Yes

No

ii)  Cancelled your insurance?

Yes

No

iii) Refused to renew your insurance?

Yes

No

iv)  Imposed penalties or special terms?

Yes

No

If “Yes”, please give full details on a separate sheet

c) Are you currently insured against the risks covered by ITIC?

Yes

No

If “Yes”, with whom?

6  Limits and Deductibles

Please indicate any preferred limits or deductibles

Limit

Deductible

Please state currency

Alternative 1

Alternative 2

7  Quality Assurance

Have you obtained quality assurance accreditation in accordance with BS5750/ISO9000

Yes

No

8  Please supply copies of any literature about your company which is relevant to this proposal

DECLARATION

I/We undertake that if this proposal is accepted I/We will act and abide and agree to be bound by the Rules of ITIC and any modification or alteration thereof made in accordance therewith from time to time and also by the decision of the Club and its Directors.

I/We declare that to the best of my/our knowledge and belief, the information given above is true and that I/We have not suppressed or misstated any material facts.   (A material fact is one likely to influence an underwriter’s assessment or acceptance of this proposal).

Signed

Status of Signatory

Date

This proposal form must be completed and signed by a person who is authorised to bind the proposer