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Hull and PNI
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Marine insurance contracts such as this one are based on the doctrine of uberrimae fidei. Simply stated, this doctrine means that both parties must use the utmost good faith when dealing with each other. In terms of your duties to us, the doctrine means that any failure to disclose a fact that may be relevant to our underwriting analysis – whether the failure to disclose is intended to deceive or whether it is completely innocent or unintentional – may result at our sole discretion in your policy being declared a nullity retroactive to its inception. This duty of total disclosure is present when you apply for insurance, during the period of coverage and at the time of renewal. The bottom line is that if you think that there is even a slight chance that some fact – whether it be about your boat, your fishery, your company or anything else touching upon this insurance – might be relevant to our decision-making process, it is your duty to tell us about it.
MLA Membership ID#
Name:
(Required)
First
Last
Port:
Address:
(Required)
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone:
Email:
(Required)
Legal Owner: (If vessel is owned by Company/Corporation, please show below):
Company Name and Address
Consent
(Required)
I consent to receive all communications, notices, and documents electronically
YOU MUST SUPPLY US WITH PHOTOCOPIES OF ALL STATE &/OR FEDERAL COMMERCIAL FISHING PERMITS AND PROOF OF OWNERSHIP WITH YOUR APPLICATION. IF OWNED BY A CORPORATION, PLEASE SUPPLY COPIES OF YOUR CORPORATION PAPERS.
I have a current mortgage on the vessel and am required by my financier to carry Breach of Warranty coverage. I understand that there will be an additional charge for this coverage.
Bank / Lienholder Name:
Contact Person:
First
Last
Phone:
Address:
Loan Account Number:
Loan Balance: $
I have an individual/company with a vested interest in my vessel and require them to be listed as a lien holder on my policy.
Bank / Lienholder Name:
Address:
Please add the following individual company as an additional insured. There is an additional charge for this endorsement
Additional Insured:
Address:
Please complete all sections.
Vessel Name:
Length:
Color:
Documentation or Registration Number:
Date of Purchase
MM slash DD slash YYYY
Purchase Price: $
Hull Model No.:
Name of person vessel was purchased from:
Year Built:
Builder:
Location:
Hull Construction: (Check one)
Fiberglass
Wood
Steel
Other (specify)
Untitled
Engine Make:
Model:
Fuel: (Check one)
Gas
Diesel
Year Engine Built:
Year Installed:
Horsepower:
Serial #:
Transmission:
Model:
Serial #:
Year Built:
Propeller:
Model:
Serial #:
Size:
Has this vessel ever been surveyed?
No
Yes
If yes, attach copy of most recent survey.
File
Drop files here or
Select files
Max. file size: 50 MB.
Please complete all sections.
Check which of the following the boat is equipped with
Radar
GPS
Stove
Compass
CB Radio
Fume Detector
Cell Phone
Detector Finder
VHF
Depth Sounder
Master Switch Alarm
Single Side-Band Radio
High Water Alarm
Life Raft
EPIRB
# _________ Survival Suit(s)
# __________ Fire Extinguishers
Anchor(s) _________ lb.
& __________ lb.
Additional Equip: (Specify)
Please complete all sections.
Amount of Hull Insurance Desired: $
Requested Effective Date:
MM slash DD slash YYYY
Amount of deductible requested for Hull Policy:
$1,000
$2,500
$5,000
Please note. Your selection of deductible will partly determine the premium charged. Please circle the deductible requested
Please describe the activity of your vessel over the course of one year.
Include months when the boat is laid up on shore and those months it is in the water. List the type of fisheries you participate in including method of fishing.
Do you participate in any Chartering Activity?
Yes
No
If indicated yes, please complete an Application for Charter.
Has any insurer ever canceled, refused or not renewed any boat insurance for applicant or vessel?
If yes, please give details:
Has this boat ever been insured with us before?
Yes
No
If yes, under what boat name:
Name of previous owner of this boat (if any):
Do you currently have a boat insured with us that will be canceled when the new policy is effective?
Yes
No
If yes, give name of boat: F/V
Effective date of Cancellation?
MM slash DD slash YYYY
Years of Experience at Sea:
Years you have operated a boat?
Will there be any operators other than yourself?
Yes
No
IF YES, YOU MUST COMPLETE AN ALTERNATE CAPTAIN’S APPLICATION AND RETURN TOGETHER WITH THIS APPLICATION.
What is the maximum distance from shore that you operate the vessel?
A vessel is considered an offshore vessel if, the vessel fishes beyond a 48 hour time frame before returning to port. Is this vessel an Offshore vessel?
Yes
No
If indicated yes, please advise the following
Distance Fished from shore: (miles)
# of Days at Sea:
Please complete all sections.
1.) Have you (in all cases, the word “you” includes your company and/or vessel) ever made an insurance claim of any kind against any Hull and/or P&I policy issued to or owned by you?
No
Yes (Please explain below)
2.) Has any crew member or employee ever made an insurance claim of any kind against any Hull and/or P&I policy issued to or owned by you?
No
Yes (Please explain below)
3.) Has any third party ever made an insurance claim of any kind against any Hull and/or P&I policy issued to or owned by you?
No
Yes (Please explain below)
4.) Have you ever made an insurance claim of any kind against any Hull and/or P&I policy not issued to or owned by you?
No
Yes (Please explain below)
If you’ve answered yes to any of the above questions, please explain:
The applicant is hereby informed, and by signing below agrees, that any survey made in respect to the applicant’s vessel by or for the insurer shall only be for the insurer’s consideration in deciding whether to insure. The survey report and the insurer’s decision to insure shall not be interpreted as a warranty or guarantee to the applicant by the insurer or by the surveyor that the vessel conforms to the survey report or that it is sound, seaworthy or fit for any specific purpose, or that it has any specific market value or condition. The applicant also understands that this vessel must be surveyed at least once every ten years or at the discretion of the Co-op and at the applicant’s expense while the policy is in effect. . The applicant is also informed and understands that once the policy is issued, any unpaid balance over 30 days from issue date may be subject to finance and collection charges.
Signature
(Required)
By signing this application, you are acknowledging that you have read and understand the above.
Date of Application:
(Required)
MM slash DD slash YYYY
Please complete all sections.
Check appropriate box(s):
I do NOT wish to have P&I coverage.
I wish to have P&I coverage as follows:
If you do NOT wish to have P&I coverage, please initial here:
P&I Coverage Desired: Policy Term: 12-months
$100,000
$300,000
$500,000
$1,000,000
Amount of deductible requested for P&I Policy: Please circle the deductible requested
$1,000
$2,500
$5,000
Please note. Your selection of deductible will determine the premium charged.
Please complete all desired sections.
Check appropriate box(s):
I do NOT wish to have crew coverage.
I wish to have crew coverage as follows:
If you do NOT wish to have crew coverage, please initial here:
Crew #1: Months desired (check)
Jan.
Feb.
Mar.
Apr.
May
Jun.
Jul.
Aug.
Sep.
Oct.
Nov.
Dec.
Fishery:
Lobster and/or Gillnet
Other
If selected other, please specify:
Crew #2: Months desired (check)
Jan.
Feb.
Mar.
Apr.
May
Jun.
Jul.
Aug.
Sep.
Oct.
Nov.
Dec.
Fishery:
Lobster and/or Gillnet
Other
If selected other, please specify:
Crew #3: Months desired (check)
Jan.
Feb.
Mar.
Apr.
May
Jun.
Jul.
Aug.
Sep.
Oct.
Nov.
Dec.
Fishery:
Lobster and/or Gillnet
Other
If selected other, please specify:
Crew #4: Months desired (check)
Jan.
Feb.
Mar.
Apr.
May
Jun.
Jul.
Aug.
Sep.
Oct.
Nov.
Dec.
Fishery:
Lobster and/or Gillnet
Other
If selected other, please specify:
The applicant is hereby informed, and by signing below agrees, that any survey made in respect to the applicant’s vessel by or for the insurer shall only be for the insurer’s consideration in deciding whether to insure. The survey report and the insurer’s decision to insure shall not be interpreted as a warranty or guarantee to the applicant by the insurer or by the surveyor that the vessel conforms to the survey report or that it is sound, seaworthy or fit for any specific purpose, or that it has any specific market value or condition. The applicant also understands that this vessel must be surveyed at least once every ten years or at the discretion of the Co-op and at the applicant’s expense while the policy is in effect. . The applicant is also informed and understands that once the policy is issued, any unpaid balance over 30 days from issue date may be subject to finance and collection charges.
Signature
(Required)
By signing this application, you are acknowledging that you have read and understand the above.
Date of Application:
(Required)
MM slash DD slash YYYY
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