General Information

Assured
Agent / Broker

If yes:

Prior Year Current Year Next Year Est.
Jones Act
LSHWA
Workers Comp
Total

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.