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ABYC Marine Insurance Application
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ABYC Marine Insurance Application
Step
1
of
8
12%
Application Information
Name of Company/Organization*
(Required)
Main point of contact (full name)*
(Required)
Email
Phone
Applicant Website URL
Yrs. Experience as Business Owner
Address
Street Address
Address Line 2
ZIP Code
Best Method of Contact *
(Required)
Yes
No
Form of your business
Form of your business
Individual
Partnership
Joint Venture
Limited Liability Company
Corporation
Other
Do you have any employees?
Yes
No
Do you or your employees have current ABYC certifications?
Yes
No
What was your total payroll for last year? (USD)
What is your projected payroll for the next 12 months? (USD)
Has any insurance company declined, canceled or non-renewed your company’s policy or coverage during the past three years?
Yes
No
Description of Operations
Which of the following Marine work do you perform?
Vessel engine repair and maintenance?
Yes
No
Vessel engine repair and maintenance revenue ($)
Vessel carpentry and finish work?
Yes
No
Vessel carpentry and finish work revenue ($)
Vessel electronics and electrical work?
Yes
No
Vessel electronics and electrical work revenue ($)
Canvas, sail and rigging work?
Yes
No
Canvas, sail and rigging work revenue ($)
Hull cleaning services?
Yes
No
Hull cleaning services revenue ($)
Hull repair work, fiberglass patching, painting, wood work?
Yes
No
Hull repair work, fiberglass patching, painting, wood work revenue ($)
Winterizing of vessels?
Yes
No
Winterizing of vessels revenue ($)
Any thru hull work?
Yes
No
Any thru hull work revenue ($)
Haul, launch or transport by water?
Yes
No
Haul, launch or transport by water revenue ($)
Other Marine Work? (please explain and provide revenues)
Haul, launch or transport by water?
Yes
No
Haul, launch or transport by water?
Yes
No
Do you perform any of the following other Marine work?
Marine Construction or dredging?
Yes
No
Gas freeing?
Yes
No
Do any of your operations include any diving?
Yes
No
Do you own any vessels which are used in your operations?
Yes
No
Where is work performed?
Mobile
On Premises
Do you perform any Non-Marine work?
Yes
No
Ship Repairer’s Liability Supplementary Questionnaire
Type of vessels worked on: (please provide percentages based on overall workload)
Ferro Cement
Steel
Fiberglass
Wood
Aluminum
Type of work: (please provide percentages based on overall workload)
Engine
Boiler
Hull
Electrical
Painting
Welding
No. of Vessels worked on last year
Average $ value of vessels
Maximum $ value of vessels
Repair Facilities Supplementary Questionnaire
Address of repair facilities
Do you own any of the following
Dry-dock
Marine railways
Marine repair piers
Is the public fire department paid or volunteer?
Paid
Volunteer
How many public fire hydrants are on location?
What is the distance?
Do you have private fire protection?
Yes
No
Is yard fenced in?
Yes
No
How long has shipyard been in operation under present management?
(Give prior business name if any)
Is area locked entry or restricted entry?
Yes
No
Owned Vessel(s) Supplementary Questionnaire
Do you own any vessels?
Yes
No
Miscellaneous Property Coverage Questionnaire
Marine Artisan’s coverage includes Miscellaneous Tools & Equipment Coverage at limits of $5,000 with a per item maximum of $1,000, subject to a $ 500 deductible. Please schedule all itemized equipment for limits in excess of the above;
Itemized equipment list
Please list the type of equipment and for each, the manufacturer, year and value
Loss Experience
List loss experiences for the past 5 years with amounts paid and outstanding (including uninsured losses).
Have you been in business for more than 3 years?
Yes
No
Signature of Insured/Owner:
Full name, this acts as your signature
Date
MM slash DD slash YYYY
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