General Information

Assured
Agent / Broker
VESSEL INFORMATION (OR ATTACH VESSEL SCHEDULE)
Vessel Name Vessel Owner Type Year Built Length Propulsion / HP Date of Last Overhaul / Repower
CARGO
LOADING/DISCHARGING
1.
2.
3.
1.
2.
3.
CHARTER PARTY
SIDE AGREEMENTS
OTHER INSURANCE

Loss Experience: Please attach Five (5) years of ground up company loss runs.

The above information, and supplemental information enclosed, is true and correct to the best on my knowledge. I understand that I am not bound to accept the insurance and that underwriters are not bound to accept this risk.