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FIREMAN'S FUND McGEE MARINE UNDERWRITERS

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FIREMAN'S FUND McGEE MARINE UNDERWRITERS Powered By Docstoc
					                                       AIG GLOBAL MARINE
       MARINE EXCESS LIABILITY / BUMBERSHOOT POLICY APPLICATION
I. GENERAL INFORMATION:
1. APPLICANT:
NAME AND ADDRESS OF THE FIRST NAMED INSURED:




CORPORATION: ( );   LIMITED LIABILITY COMPANY ( );   PARTNERSHIP ( );        INDIVIDUAL ( )
2. SUBSIDIARY OR AFFILIATED COMPANIES:
SCHEDULE ALL SUBSIDIARY OR AFFILIATED COMPANIES TO BE INSURED:




3. PRODUCER:
NAME AND ADDRESS OF PRODUCER:




PRODUCER'S CONTACT NAME(S):                               TELEPHONE NUMBER:

4.   POLICY TERM:
FROM:                            TO:                     TIME:                  STANDARD TIME:
5. LIMITS:
LIMIT REQUESTED:     LAYER I:      $                   EXCESS OF:       $ (EXCESS OF PRIMARY)
                     LAYER II:     $                   EXCESS OF:       $
                  LAYER III:       $                   EXCESS OF:       $
6. EXPIRING INFORMATION:
CARRIER:                                                  LAYER:        PREMIUM:
                                                             I          $
                                                             II         $
                                                             III     $
7. OPERATIONS:
a. PROVIDE A COMPLETE DESCRIPTION OF ALL OPERATIONS FOR ALL NAMED INSUREDS:




YEARS IN BUSINESS:      ___________ YEARS
8.   REVENUES AND PAYROLLS:
                                           ESTIMATED GROSS   ESTIMATED FIELD     NUMBER OF FIELD
NAME OF ENTITY:                               REVENUES:         PAYROLL:           EMPLOYEES:
                                           $                 $
                                           $                 $
                                           $
                                           $                 $
                                           $                 $
TOTAL:                                     $                 $

II. NON-MARINE EXPOSURES:
9. PREMISES OCCUPIED BUT NOT OWNED (BY THE APPLICANT WITH VALUE IN EXCESS OF $25,000):
                                       PERCENT (%)           ESTIMATED               80% BUILDING
PREMISES DESCRIPTION:                   OCCUPIED:              VALUE:                  FIRE RATE:
                                                 %           $                           %
                                                 %           $                           %
                                                 %           $                           %
                                           %         $                          %
10. NON-MARINE PERSONAL PROPERTY IN YOUR CARE, CUSTODY OR CONTROL (VALUES EXCEEDING $25,000):




OR, IF NONE, CHECK HERE: ( )
11. CONTRACTUAL LIABILITY:
PROVIDE DETAILS OF YOUR WRITTEN CONTRACTUAL AGREEMENTS:




OR, IF NONE, CHECK HERE: ( )
12. PRODUCTS LIABILITY:
                               LIST PRODUCTS:                      LIST ESTIMATED ANNUAL SALES:
MANUFACTURED:                                                      $
SOLD:                                                              $
DISTRIBUTED / INSTALLED:                                      $
13. PROFESSIONAL LIABILITY/MALPRACTICE:
PROVIDE DETAILS OF ANY ACTIVITIES THAT MIGHT INVOLVE MALPRACTICE AND/OR ERRORS AND
OMISSIONS EXPOSURES:



OR, IF NONE, CHECK HERE: ( )
14. RAILROAD OPERATIONS:
PROVIDE DETAILS OF ANY RAILROADS OR RAILROAD SIDE TRACKS THAT YOU OWN, MAINTAIN OR
OPERATE:



OR, IF NONE, CHECK HERE: ( )


                                                                                                    2
15. AUTOMOBILE EXPOSURE:
TYPE:                                 NUMBER:          OPERATING RADIUS:           CARGOS CARRIED:
PRIVATE PASSENGER AUTOS:                                            MILES
VANS &PICKUPS:                                                      MILES
TRUCKS:                                                             MILES
TRACTORS:                                                           MILES
TRAILERS:                                                           MILES
TANKERS:                                                            MILES
Other (                    ):                                       MILES
16. WORKMAN'S COMPENSATION:
IS STATUTORY WORKMAN'S COMPENSATION CARRIED?                                         ( ) YES ( ) NO
IF NOT, IS APPLICANT A QUALIFIED SELF INSURER?                                       ( ) YES ( ) NO
IS ANY EXCESS WORKMAN'S COMPENSATION INSURANCE CARRIED?                              ( ) YES ( ) NO
WHAT IS EMLOYER'S LIABILITY LIMIT?                                                   $
17. AIRCRAFT EXPOSURE:
DESCRIBE OWNED AIRCRAFT:



DESCRIBE LEASED OR CHARTERED / NON-OWNED AIRCRAFT:



18. ADVERTISING EXPOSURE:
DESCRIBE METHODS AND EXPENDITURES:                                       ADVERTISING BUDGET:

                                                                         $

IS AN ADVERTISING AGENCY USED?                                           ( ) YES ( ) NO
19. EXPLOSIVES:
DOES APPLICANT DO ANY BLASTING OR USE EXPLOSIVES?                                    ( ) YES ( ) NO
20. NON-MARINE LIABILITY LOSSES (5 YEAR HISTORY; OVER $5,000):
                                                                              LOSS & LOSS
 TYPE OF     DATE OF                                      LOSS & LOSS          EXPENSE            TOTAL
COVERAGE:     LOSS:           LOSS DESCRIPTION:          EXPENSE PAID:       OUTSTANDING:       INCURRED:
                                                         $                   $              $
                                                         $                   $              $
                                                         $                   $              $
                                                         $                   $              $
                                                         $                   $              $
                                                         $                   $              $
                                                         $                   $              $
                                                         $                   $              $
                                                         $                   $              $
                                                         $                   $              $
                     (IF MORE ROOM IS NEEDED, PLEASEATTACH A SEPARATE SHEET).



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III. MARINE EXPOSURES
21. WHARFINGER’S LIABILITY:
LIST BELOW ANY LANDING PIER OR WHARF LEASED OR OPERATED BY THE APPLICANT WHERE NON-OWNED
VESSELS COME UNDER THE CARE, CUSTODY OR CONTROL OF THE APPLICANT.
                                 ESTIMATED ANNUAL      RIVER AND MILE     ESTIMATED GROSS
           LOCATION:                VESSEL DAYS:          MARKER:              SALES:
                                                                          $
                                                                          $
                                                                          $
22. TERMINAL OPERATOR’S AND/OR STEVEDORE’S LIABILITY:
LIST BELOW ANY MARINE TERMINAL OR STEVEDORE OPERATION:
                                     PRINCIPAL         RIVER AND MILE         ESTIMATED GROSS
           LOCATION:            PRODUCTS HANDLED:         MARKER:                  SALES:
                                                                          $
                                                                          $
                                                                          $
23. SHIPBUILDING, SHIPREPAIRING, OR BARGE CLEANING:
LIST BELOW ANY SHIPBUILDING, SHIPREPAIRING, OR BARGE CLEANING OPERATION:
            LOCATION:                   DESCRIBE OPERATIONS:         ESTIMATED GROSS SALES:
                                                                   $
                                                                   $
                                                                   $
DOES THE APPLICANT ENGAGE IN ANY GAS FREEING?                             ( ) YES ( ) NO
IF YES, DESCRIBE:


24. CHARTERER’S LIABILITY:
DOES THE APPLICANT EVER CHARTER OR LEASE VESSELS?                         ( ) YES ( ) NO
IF YES, DESCRIBE:



25. PRIVATE PLEASURE WATERCRAFT:
DOES THE APPLICANT OWN, OPERATTE OR CHARTER ANY PRIVATE PLEASURE          ( ) YES ( ) NO
WATERCRAFT? IF YES, DESCRIBE:



26. LONGSHOREMAN'S AND HARBOR WORKER'S ACT:
DOES THE APPLICANT HAVE EXPOSURE UNDER THE LONGSHOREMAN'S AND HARBOR   ( ) YES ( ) NO
WORKER'S ACT? IF YES, LIST BELOW:
   NO. OF EMPLOYEES:         USL&H PAYROLL:           TYPE OF WORK PERFORMED:
                       $




                                                                                                4
27. COMMERCIAL WATERCRAFT:
SCHEDULE ALL COMMERCIAL VESSELS THE APPLICANT OWNS, LEASES, CHARTERS OR OPERATES. IF MORE
ROOM IS NEEDED, ATTACH A SEPARATE SHEET:
                         TYPE OF VESSEL AND PARTICULARS
                      (YEAR BUILT, DIMENSIONS, HORSEPOWER,                   NUMBER OF
       NAME:                          GRT):                  HULL VALUE:       CREW:
                                                           $
                                                                    $
                                                                    $
                                                                    $
                                                                    $
                                                                    $
                                                                    $
                                                                    $
28. MARINE LIABILITY LOSSES (5 YEAR HISTORY; CLAIMS OF $5,000):
                                                                            LOSS & LOSS
 TYPE OF      DATE OF                                       LOSS & LOSS      EXPENSE            TOTAL
COVERAGE:      LOSS:           LOSS DESCRIPTION:           EXPENSE PAID:   OUTSTANDING:       INCURRED:
                                                           $               $              $
                                                           $               $              $
                                                           $               $              $
                                                           $               $              $
                                                           $               $              $
                                                           $               $              $
                                                           $               $              $
                                                           $               $              $
                                                           $               $              $
                                                           $               $              $
                                                           $               $              $
                                                           $               $              $
                                                           $               $              $
                                                           $               $              $
                                                           $               $              $
                                                           $               $              $
                                                           $               $              $
                                                           $               $              $
                                                           $               $              $
                                                           $               $              $
                                                           $               $              $
                     (IF MORE ROOM IS NEEDED, PLEASEATTACH A SEPARATE SHEET)



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IV. SCHEDULE OF UNDERLYING INSURANCES:
29. SCHEDULE OF UNDERLYING INSURANCE:
LIST ALL LIABILITY AND COMPENSATION POLICIES TO APPLY AS UNDERLYING INSURANCE.
   TYPE OF INS.:     INSURANCE CO.:   POLICY PERIOD:        LIMITS:            PREMIUM:
GENERAL                                                                  $
LIABILITY:                                                               RATE IF M&D:
PRODUCTS                                                                 $
LIABILITY:                                                               RATE IF M&D:
SHIP REPAIRER’S                                                          $
LIABILITY:                                                               RATE IF M&D:
WHARFINGER’S                                                             $
LIABILITY:                                                               RATE IF M&D:
STEVEDORE’S                                                              $
LIABILITY:                                                               RATE IF M&D:
TERMINAL                                                                 $
OPERATOR’S
LIABILITY:                                                               RATE IF M&D:
CHARTERER’S
LIABILITY:                                                               $
PROTECTION &
INDEMNITY:                                                               $
WATERCRAFT
POLLUTION
LIABILITY:                                                               $
HULL &
MACHINERY
(C&T):                                                                   $
MARITIME
EMPLOYER’S                                                               $
LIABILITY:                                                               RATE IF M&D:
EMPLOYER’S
LIABILITY:                                                               $
AUTO
LIABILITY:                                                               $
OTHER:
                                                                         $

                                                                         $

                                                                         $
DO ABOVE POLICIES APPLY TO ALL COMPANIES OR OPERATIONS?                      ( ) YES ( ) NO
HAS ANY COVERAGE LISTED ABOVE BEEN CANCELLED OR RENEWAL REFUSED              ( ) YES ( ) NO
WITHIN THE LAST 5 YEARS? IF SO, STATE EACH COVERAGE AND THE REASON FOR
CANCELLATION OR NON RENEWAL:




30. SELF INSURED RETENTION:
WHAT SELF-INSURED RETENTION LIMITS ARE REQUESTED?                            $




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31. UNDERLYING COVERAGE:
PLEASE CONFIRM COVERAGE PROVIDED BY THE REQUESTED SCHEDULE OF UNDERLYING COVERAGE:
COMMERCIAL (CGL) AND/OR MARINE (MGL) GENERAL LIABILITY:
                                                    ARE ANY OF THE FOLLOWING MARINE
DOES THE CGL / MGL POLICY INCLUDE:                  COVERAGES PROVIDED?
  BROAD FORM CONTRACTUAL       ( ) YES   (   ) NO     SHIP REPAIRER’S LIABILITY: ( ) YES      (   ) NO
  IN REM                       ( ) YES   (   ) NO       DEMURRAGE                ( ) YES      (   ) NO
  GULF OF MEXICO EXTENSION     ( ) YES   (   ) NO       DETENTION                ( ) YES      (   ) NO
  EMPLOYEE BENEFITS            ( ) YES   (   ) NO       OTHER WORK               ( ) YES      (   ) NO
  BLANKET NAME & WAIVE         ( ) YES   (   ) NO       TRAVELING WORKMAN        ( ) YES      (   ) NO
  ACTIONS OVER                 ( ) YES   (   ) NO       CONTRACTUAL              ( ) YES      (   ) NO
  NON-OWNED WATERCRAFT         ( ) YES   (   ) NO     WHARFINGER’S LIABILITY:    ( ) YES      (   ) NO
  PER PROJECT ENDORSEMENT      ( ) YES   (   ) NO       DEMURRAGE                ( ) YES      (   ) NO
                                                        CONTRACTUAL              ( ) YES      (   ) NO
ARE THE FOLLOWING PERTINENT CGL / MGL                 STEVEDORE’S LIABILITY:     ( ) YES      (   ) NO
EXCLUSIONS INCLUDED?                                    DEMURRAGE                ( ) YES      (   ) NO
  PUNITIVE DAMAGE            ( ) YES ( ) NO             CONTRACTUAL              ( ) YES      (   ) NO
  POLLUTION EXCLUSION        ( ) YES ( ) NO           TERMINAL OPS.’ LIABILLITY: ( ) YES      (   ) NO
  HEALTH HAZARD              ( ) YES ( ) NO             DEMURRAGE                ( ) YES      (   ) NO
  OWNED WATERCRAFT           ( ) YES ( ) NO             CONTRACTUAL              ( ) YES      (   ) NO
  PRODUCT RECALL             ( ) YES ( ) NO           WATERCRAFT LIABILITY       ( ) YES      (   ) NO
  EMPLOYMENT PRACTICES       ( ) YES ( ) NO           CHARTERER’S LIABILITY:     ( ) YES      (   ) NO
  PROFESSIONAL LIABILITY     ( ) YES ( ) NO             INCLUDING CARGO          ( ) YES      (   ) NO
                                                        INCLUDING CREW           ( ) YES      (   ) NO
IS POLLUTION COVERAGE PROVIDED?
   TIME ELEMENT / SUDDEN &                            PLEASE LIST ANY OTHER NOTABLE COVERAGE
     ACCIDENTAL?             ( ) YES ( ) NO           OR EXCLUSION:
   OTHER COVERAGE:           ( ) YES ( ) NO
     (IF YES, EXPLAIN BELOW)


LIMITS AND EXPENSES:
  ARE EXPENSES OUTSIDE THE
     LIMIT?                     ( ) YES ( ) NO
  IS THE DEDUCTIBLE A PART
     OF THE LIMIT?              ( ) YES ( ) NO
  ARE CLAIM EXPENSSES
     SUBJECT TO THE DEDUCT.?    ( ) YES ( ) NO
PROTECTION & INDEMNITY (P&I):
DOES THE P&I POLICY INCLUDE:
  CONTRACTUAL COVERAGE?                                                           (   ) YES   (   ) NO
  IN REM COVERAGE?                                                                (   ) YES   (   ) NO
  IS THE “OTHER THAN OWNER” REFERENCE DELETED?                                    (   ) YES   (   ) NO
  BLANKET NAME & WAIVE?                                                           (   ) YES   (   ) NO
  IS PRIMARY COLLION & TOWER’S COVERED IN THE P&I?                                (   ) YES   (   ) NO




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I/WE HEREBY WARRANT THAT THE INFORMATION PROVIDED ABOVE IS COMPLETE AND ACCURATE TO THE
BEST OF MY/OUR KNOWLEDGE AND BELIEF. IT IS OUR UNDERSTANDING THE UNDERWRITERS WILL RELY
UPON THE INFORMATION AND REPRESENTATIONS LISTED ABOVE HEAVILY IN DETERMINING THE
ACCEPTABLILITY AND RATES AND CONDITIONS OF COVERAGE. IT IS FURTHER UNDERSTOOD THAT ANY
MISREPRESENTATION OR OMISSION MAY CONSTITUTE GROUNDS FOR IMMEDIATE CANCELLATION AND
DENIAL OF CLAIMS.
IT IS FURTHER UNDERSTOOD THAT THIS APPLICATION SHALL BE ATTACHED TO AND FORM PART OF THE
POLICY SHOULD ONE BE ISSUED.
32. SIGNATURES:

INSURED:          SIGNATURE:

                  PRINT:                                          DATE:

AGENT:            SIGNATURE:

                  PRINT:                                          DATE:




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