Application for Bumbershoot Insurance

General Information

Name

1. APPLICANT: (Include all Companies to be insured)

2. ADDRESS:

3. OPERATIONS:

4. SIZE OF OPERATIONS:

A. Payroll Annual

B. Receipts Annual

C. Annual Advertising Expenditure

D. No. of Employees (Excluding Shipboard)

E. No. of Shipboard

5. METHOD OF ADVERTISING:

6. DETAILS OF ON-SHORE OPERATIONS:

A. Leased property for which applicant is responsible:

B. List docks, piers and terminal, etc., where applicant maintains cargo facilities:

C. Other property in applicant's care, custody and control:

7. DETAILS OF ANY CONTRACTUAL LIABILITY AGREEMENT, OR GENERAL AGENCY AGREEMENT:

8. NUMBER OF AND TYPES OF OWNED AND/OR LEASED:

A. Aircraft

B. Watercraft (list "Oceangoing" vessels separately by name if possible)

9. PRIMARY INSURANCE COVERAGES AND EXPOSURES (If no known exposure, so indicate)

A. Amount P & I (List any unusual exclusions and indicate type policy. Schedule vessels with separate values if possible and show insurance carrier).

B. Amount Excess P & I Insurance and Carrier

C. Amount War Risks P & I and Insurance Carrier

D. Amount Deviation Liability Insurance and Insurance Carrier

E. Amount "Cargo Bailee" or "Dock Liability" Insurance or Terminal Operators and Carrier

F. Amount Hull Insurance and Carrier (Schedule, separately and note any limitations on collision liability)

G. Amounts on Excess Collision and Excess Liability (GA Salvage, etc. and Carrier)

H. Amounts of Charterer's Liability, Stevedores Legal Liability, S. R. Legal Liabilities or Other Marine Legal or Contractual Liabilities (Specify type, amount and carrier)

I. Amounts and Insurance Carrier on Auto BI and PD (Give approximate number of vehicles)

J. Amounts and Carriers on Workmen's Compensation (Describe and Jones Act or Federal Longshoreman's Act exposures and give applicable payrolls)

K. Amount and Carriers or Advertisers Liability, Aircraft Liability, Malpractice, if applicable.

L. General Liability (Indicate limits and carrier)

10. DETAILS LIABILITY LOSSES, INSURED OR UNINSURED, SETTLED OR PENDING EXCEEDING $25,000 IN LAST FIVE YEARS.

11. DETAILS OF ANY SPECIFIC LIMITATIONS OR EXCLUSIONS IN PRIMARY INSURANCE NOT OTHERWISE NOTED:

12. DESCRIBE ANY KNOWN DEFICIENCIES OF INSURED OR ANY OTHER RELEVANT FACTS WHICH MIGHT EFFECT UNDERWRITER'S JUDGMENT WHEN CONSIDERING THIS APPLICATION:

13. LIMITS DESIRED:

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 the Applicant to accept the insurance nor oblige the insurer to effect insurance on the risk.

Broker / Agent’s Signature

Applicant’s Signature

Company Name / Branch

Title

Date

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