Terra Nova Insurance Company Ltd.

PROTECTION & INDEMNITY
INSURANCE APPLICATION FORM

Section I - Applicant:

Applicant's name and address:

Principal(s) and/or Owner(s):

Period Applicant has operated vessels?

For how long has Applicant's company been trading

List ALL previously owned and/or associated and/or affiliated maritime related companies that Applicant has been involved in:

Has the Applicant and/or its affiliated companies been involved in bankruptcy proceedings? If Yes, Specify details on a separate sheet.

Please provide full details of the nature and extent of the Applicant's operations, including those of any subsidiary and/or affiliated company that Applicant is currently associated with:


Section II - Crew & Employees:

Does Applicant require Cover for Crew?

Applicant's Total number of employees

Total number of Crew employed

Nationality of crew: Officers
Ratings

Maximum crew working on board at any one time:

Is a Personal Accident Policy/Health Care Plan in force?

Please provide details of any National or State health benefit that is available to the crew.

Please give details of selection/ pre-employment programme carried out by the Applicant for new crew:

Does the above apply to ALL newly recruited crew?

Number of employees on board, other than crew specified herein?

Why are these other employees on board the Applicant's vessels?

Please provide a copy of your standard Crew contract or detail any and all liabilities arising under Crew contracts in respect of illness or injury for which the Applicant requires coverage


Section III - Third Parties on Board:

Please provide details of all 'third party' personnel living on or working from the scheduled vessels

Describe the circumstances under which these 'third party' personnel are on board the Applicant's vessels:

Are these personnel living/ working there as part of work under a contract?

If Yes, please give details of work carried out by them and the insurance requirements arising under the contract (please provide copy):


Section IV - Cargo:

Does the Applicant require cover for Liability to Cargo?

Specify type of cargoes carried:

Will the vessel carry Containers and/or Reefer – please expand

Specify max value per shipment:

Specify limit of liability required under the P&I insurance policy:

Please give details of Standard Contract of Carriage:


Section V - Current Policies:

Has the Applicant and/or affiliated companies ever been denied coverage or been subject to policy cancellation by Underwriters?

If Yes, please provide details:

Name of present/latest P&I Insurer:

Date current P&I Policy expires:

Current Hull & Machinery Policy terms: Does Hull Policy include: ¼ RDC/ 4/4 RDC/ No RDC/ Fixed and Floating Objects (Delete as applicable)


This vessel detail schedule should be copied and completed for each vessel owned and/or operated by the Applicant. Any additional vessels that may be attached during the year should be submitted in the same format.
Section VI - Vessel Details:

Vessel name:

Type:

Gross Tonnage:

Built:

Flag:

Dimensions (L,B,D):

Classification Society:

Outstanding Conditions of Class, if any:

Is the vessel owned by the Applicant?

Date purchased:

Is vessel under a charter or similar contract?

If Yes, please give details:

Please specify ownership details:

Date of last engine overhaul:

Date of last Special Survey:

Insured value (US$):

Number of crew on board any one time:

Number of other employees:

Is this vessel used to carry passengers:

If Yes, specify passenger capacity for which vessel is licensed:

Are passengers issued with a Standard Passenger Ticket?

If Yes, please provide copy:

Has SOLAS 1994 Requirements (Section 3-6) been complied with?

Has a Safety Management Certificate been issued?

What is status with regard to July 2002 ISM Code compliance for the vessel?


Section VII - General:

Where is the vessel expected to Trade during the next 12 months?

Please give details of all contractual obligations the Applicant might incur as they relate to this requested Insurance:

Have the Applicant's operations been subject to a Risk Management assessment or an independent safety audit?

If Yes, please give details of such assessment/audit and recommendations, including whose advisory services were used and date when implementation took place (please use separate sheet).

Has the vessel(s) named in this Application been the subject of a P&I Condition Survey within the last 12 months?

If YES, where, when and by whom was it carried out?

Please give details of any change of Class over the past 3 years

Please attach company brochure, if any.



We hereby warrant that the information we have given, at the date of signing this application, is complete and accurate to the best of our knowledge and belief. It is our express understanding that Insurers rely upon the information and representations given in determining the acceptability of this application and in setting rates and conditions of coverage.

It is understood that any misrepresentation or omission shall constitute grounds for immediate cancellation of coverage and no claims will be paid.

It is further noted and understood that the Applicant is under a continuing obligation immediately to notify Insurers of any material alteration to the nature, extent or size of his operation as described herein.

It is further understood that this application shall be attached to and form part of any Policy subsequently issued.

Applicant:	Signed:

Title:

Date:

(Please Print)

Section VIII - Protection and Indemnity Loss Information:

Please list all known incidents, potentially involving P&I, for the previous FIVE years whether or not P&I cover was in force at the time. The list must include ALL previously Closed Claims, including those Closed without payment, ALL incidents whether an 'estimate of loss' has been set or not and ALL other Claims where an estimate has been set and/or payments made (N.B. all figures should contain Legal Fees and Expenses). Specify also the date at which the claim reserve and/or last review took place. The above information must be reported for ALL vessels operated by the Assured and/or Affiliated Companies for the previous FIVE years, whether or not the vessels appear on the attached schedule and displayed in the format set out below.

Year		Name of Insurer (if any)
No of vessels operated this year No. of Crew this year Vessel utilisation rate (%)

Type of Claim	Date	Vessel	Paid amount (US$)	Reserve amount	Loss details