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1
General Information (if additional space is
required please list separately)
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a) Date established
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b) Name and address of any Subsidiary,
affiliated or associated companies which you wish to cover.
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Name and Address
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Principal Activity
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c) Address of all branch offices to be
included in the cover
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d) No. of Directors/Partners
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Total no. of staff engaged in providing
Services listed in Question 2 e)
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e) Names, positions, professional
qualifications and number of years’ experience of Directors/Partners
and Senior Managers
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f) Name of person to whom correspondence
should be addressed
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g) Are you a Member of any Trade
Association – please detail
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2
Gross Annual Income (fee and commission
earned)
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a) Please indicate currency e.g. US$
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b) Last financial year
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c) Estimate for this financial year
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d) Estimate for next financial year
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dd) Of which estimated income from UK
operations (if applicable)
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e) Please indicate the percentage of your
Gross Annual Income from the following activities to be
insured
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Tramp Agent
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%
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Bunker Broker
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%
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Liner Agent
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%
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Ship Manager*
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%
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Chartering Broker
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%
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Freight Forwarder*
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%
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Sale & Purchase Broker
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%
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Forwarding Agent
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%
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Marine Surveyor
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%
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Representative of Insurance Interests
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(e.g. P&I
Clubs, Corporation of Lloyds, Classification Societies)
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%
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Other activities for which insurance is
required (please specify)
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%
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(Please also
complete supplementary form*)
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3 Principals
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Please name the Principals for whom you
regularly act
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Do you have any financial interest in any
of your principal’s companies?
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Yes
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No
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Do your principals have any financial
interest in your company?
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Yes
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No
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4 Contract
Conditions
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a) Do you operate under Standard/National
Contract Conditions?
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Yes
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No
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b) Do you operate under your own Contract
Conditions?
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Yes
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No
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c) If “Yes” to either of the above, do you
always advise your customers
that Contract Conditions apply?
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Yes
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No
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Please supply
copies of all Contract Conditions under which you operate
If “Yes” to (as) or (b) please give details on a separate sheet
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5 Claims
History
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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?
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Yes
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No
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