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Insurance Information
Claims
Surveyors Information
About
Contact

Alternate Captain

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Step 1 of 2

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This field is for validation purposes and should be left unchanged.

Please complete all sections.

Owners Name:(Required)

First Last

Phone:

Email(Required)

Address:

Street Address Address Line 2 City State ZIP Code

Vessel Name: F/V

Port:

Requested Alternate Captain relationship to owner:

Reason for needing an Alternate Captain:(Required)

Owner's Signature:(Required)

Date(Required)

MM slash DD slash YYYY

Please complete all sections.

Full Name of Requested Alternate Captain:

First Last

Address

Street Address Address Line 2 City State ZIP Code

Date of Birth:

MM slash DD slash YYYY

Yrs. Exp. at Sea:

Yrs. Exp. Operating:

Yrs. Commercial:

Commercial Permit?

Yes

No

Permit #:

Yr. Issued:

Type:

Captains License?

Yes

No

Type:

Six Pack

Master License

Prior Incidents?

Yes

No

If yes, describe incident:

Amount Paid by Insurer: $

Previous Employers Name:

First Last

Port:

# of Years:

In what capacity?

Please provide at least 2 names of people of whom you have operated a commercial fishing vessel as an Alternate Captain

Name:

First Last

Phone:

Name:

First Last

Phone:

Requested Alternate Captain Signature:(Required)

Date(Required)

MM slash DD slash YYYY

Office Use ONLY: Date:

Untitled

Approved

Declined

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781-545-5073
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