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Fort Lauderdale • Cocoa, Florida • Newport, RI • Special Risks

Commercial Marine Insurance

The Atlass Insurance Group is Fully Committed to
the International Maritime Community

The scope of coverage available to our clients is complete and comprehensive for commercial hull & marine insurance.

We represent many leading domestic insurers and maintain contact with the London Market, and other European underwriters. The Atlass Insurance Group represents only "A" rated companies.

Hull and P&I

Charter Vessels
Ferry Boats
Excursion, Sightseeing
Dinner Boats
Research Vessels
Cruise Ships
Casino Boats
Tugs, Barges, Dredges

Marinas

Ship Yards
Boat Dealers
Boat Builders
Marine Contractors
Marine Artisans
Wharfingers & Stevedores Liabilities
Crew Medical

Maritime Employer's Liabilities

Mel
USL&H
Jones Act
Umbrellas
Bumbershoots

Atlass Insurance Group Commercial Hull Application

* Required

Section I - Application

* Name:

* Email:

* Phone:

Applicant Address:

Period applicant has operated vessels (years) :

Period of time Applicants Company named herein has been trading?

Please 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?
Yes No

If yes, please specify.

Please provide full details of the nature and extent of the applicants operation, including those of any subsidiary and/or affiliated companies which applicant is currently associated with:

Specify navigation limits required:

Limit of coverage required:

Period of coverage required: months

If a tank barge operator, please Email details of O.P.A. compliance plan.

Section II - Current Policies

Has the applicant and/or affiliated companies been denied coverage or been subject to cancellation by underwriters?
Yes No

If yes, please provide details:

Is personal accident policy/health care plan in force? Yes No

Is separate maritime employer's liability policy in force? Yes No

Is a comprehensive general liability policy in force? Yes No

If yes,

1. Is the "watercraft exclusion" deleted? Yes No

2. Is "Contractual cover" included? Yes No

Name of Current Hull and P&I insurers:

Number of years insured by current insurer?

Date of expiration:

Section III - Loss Prevention

Have the applicants operations been subject to an independent safety audit?
Yes No

If yes, please give details of audit and recommendations including whose advisory services were employed and when did implementation take place?

Section IV - Crew/Employees/Others

Total number of employees employed by applicant, incl. crew:

Total gross receipts for last 12-month period:

Total gross payroll for last 12-month period:

Total gross "Jones Act" payroll for last 12 months:

Total number of crew employed by the applicant:

Maximum number of crew working on applicant's vessels any one time:

Does the crew work on a "time shift" basis? Yes No If yes, please specify:

a. Period of time for each shift: hours

b. Number of shifts in any one 24 hour day: hours

c. Number of crew assigned to each shift: crew

Does the crew for one shift remain onboard after being relieved by the next shift?
Yes No

Are the crew issued with deck hand manuals? Yes No

Please specify crew names and their appointed crewing positions and the period of time for which they have been employed by the applicant, stating the details of any licenses held by those persons navigating applicants vessels.

Name - Position - Licenses - Date of Employment

Please give details on any pre-employment program carried out by the assured prior to the hiring of any crew:

Are the above carried out for all newly appointed employees: Yes No

If yes, are records available for scrutiny? Yes No

Are the crew employed through crewing agencies/labor pools? Yes No

Number of employees onboard other than crew specified herein:

Describe the circumstances under which these other employees are onboard applicants vessel:

Are there any third party personnel quartered on or working from the scheduled vessels?
Yes No

Describe the circumstances under which these third party personnel are
onboard applicants vessel(s)

Is such "third party" personnel quartered on or working from the scheduled vessel under a contract? Yes No

If yes, please give details of work carried out by them and the insurance requirements of your contract (which if written please provide a copy of said contract, if any).

Section V - Vessel Details

Vessel name:

GRT:

Year built:

Type of vessel:

Construction material:

Dimensions:

Does vessel carry cargo? Yes No

In which classification society is vessel entered?

Does applicant own the vessel? Yes No

Date purchased:

Is the vessel under charter or similar contract? Yes No

If yes, please give details:

Please specify owner details:

Date of last engine overhaul:

Number of engines:

Horsepower each:

Insured value:

Hull policy form:

Number of crew:

Number of other employees:

Is the vessel licensed to carry passengers? Yes No

If yes, please specify US Coast Guard passenger capacity limitations

Are the passengers issued a standard passenger ticket? Yes No

If yes, please give details:

(N.B. 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 a similar format.)

Section VI - Loss Information

Please list all reported incidents for the previous five years. The list must include all previously closed claims, including those closed without payment, all incident 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 or 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 vessel appears on the attached schedule and displayed in the format set out below:

Year: To

Name of insurer:

Number of vessels operated in this year:

Vessels:

Number of crew applicable to this year:

crew

Vessel utilization applicable to this year:

Claiment's Name - D.O.L .- Vessel - Paid Amount - Reserve Amount - Reserve - Detail of Loss

Section VII - General Cargo

Does the applicant require ship owner's liability to cargo? Yes No

If yes,

a. Specify types of cargos carried:

b. Specify maximum values per shipment:

c. Specify limit of liability required:

Please give details of standard contract of carriage:

Contractual

Please give details of contractual obligations the applicant might incur as they relate to this requested insurance:

Please Mail or Email company brochures.

I/we hereby warrant that the information provided above is complete and accurate to the best of my/our knowledge and belief. Its my/our understanding that the underwriters shall rely on the information and representation listed above in determining the acceptability, rates and conditions of coverage.

It is understood that any misrepresentation or omission shall constitute ground for immediate cancellation of coverage and denial of claims, if any.

It is further noted and understood that the applicant is under a continuing obligation immediately to notify his underwriter's 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 the policy should one be issued.

Applicant:

Title:

Date:

Remarks: