Document Sample
					                                                Galleon Marine Insurance Agency
                                     10 Fenchurch Avenue, London, EC3M 5BN, United Kingdom
                   E-mail: Telephone: +44 (0)20 3178 8866 Fax: +44 (0)20 7663 5700

                                              CARGO HANDLING INSURANCE
                                                          Confidential proposal form
              •     This form may be completed by your authorised insurance broker
              •     Please attach any relevant company literature which may assist us with your enquiry
              •     If you have insufficient space to answer any questions, please attach a separate sheet
              •     It is your duty to disclose all material information to Underwriters that may affect the premium or
                    terms and conditions offered

Details of the Applicant

Company Name:

Company Address:

E-mail:                                                                        Telephone:

Website:                                                                        Date Established:

Have you obtained quality assurance accreditation from any nationally recognised organisation?
If “yes”, please specify:

Please detail names of any trade associations to which you are affiliated or are members:

Names and addresses of any subsidiary, affiliated and associated companies or locations which you wish to include in the

Details of the Key Personnel

Please list your directors or partners, noting their professional qualifications or number of years experience:

Number of Directors, Partners or Senior Managers:

Number of Clerical Staff:

Number of Manual Staff:

Total Number of Employees:

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               Galleon Marine Insurance Agency is a trading name of Crispin Speers & Partners Limited which is authorised and regulated by
               the Financial Services Authority (FSA) with FSA registration number 311507. Registered in England with registration number
                                    01960404. Registered Office: St Clare House, 30-33 Minories, London, EC3N 1PE
Financial Details

Please state your gross revenue for the previous 12 months:
Currency = ………………..
Please state your gross revenue for the next 12 months:

                                              The previous 12 months                       The next twelve months
(please advise cargo throughputs)
Break Bulk (tonnes)
Dry Bulk (tonnes)
Wet Bulk (tonnes)
Other (please detail)

Vessel Call per annum                         The previous 12 months                       The next twelve months
Up to 5,000 GT
5,001 to 15,000 GT
Over 15,001 GT

                                       No. of      Approximate
                                                                    Location of Services
            Service                    years       % of annual                                    Cargoes Handled
                                     experience      revenue


Marine Terminal Operator

Container/trailer freight station

Container/trailer storage

Inland Clearance Depot (ICD)

Airfreight terminal/depot


Local collection and delivery

Depot operator

Equipment repair/refurbishment

Waste disposal

Advice to other operators

Operating a chassis pool


Other (please detail)

                                                      Page 2 of 4

 Are any services subcontracted out? (If “no”, please proceed to next section)                                                     YES        NO

 Please indicate which services and what percentage of your annual revenue is paid to subcontractors:

 Do you contract on a back to back basis with sub-contractors? (i.e. is the subcontractor required to comply with
                                                                                                                                   YES        NO
 all relevant obligations of the main contract you operate under with your customer).

 Do you check annually that all subcontractors maintain and renew their insurance?                                                 YES        NO

 Is there a requirement in your contract with subcontractors that they have adequate liability and
 property insurance                                                                                                                YES        NO
 If “YES”, what is the minimum limit you require? CURRENCY: ………… LIMIT: …………………………………..

Contracts, Indemnities and Trading Conditions

  Do you ever indemnify another person or company for their liability under any agreement?
                                                                                                                                  YES         NO
  If “yes”, please detail separately

  Do you ever waive any rights of recourse in favour of another person or company?
                                                                                                                                  YES         NO
  If “yes”, please detail separately

  Please indicate which documents and trading conditions you are currently using:

                OWN STANDARD CONTRACT                              YES        NO         OWN INDIVIDUAL CONTRACT                   YES        NO

                          NO CONTRACT                              YES        NO        PORT TARIFF/ACT/BYLAWS                     YES        NO

 Other (please specify):

Insurance Details

 Have any claims been made against you, or have there been any circumstances likely to give rise to a
 claim being made against you, in the last 5 years?                                                                                YES        NO
 If “yes”, please provide details on a separate sheet

 Has any Insurer ever declined to insure you?                                                                                      YES        NO

 Has any Insurer ever cancelled your insurance?                                                                                    YES        NO

 Has any Insurer refused to renew your insurance?                                                                                  YES        NO
 Has any Insurer previously imposed any special policy terms, conditions or exclusions? If “yes”, please
                                                                                                                                   YES        NO
 provide details on a separate sheet

 Are you currently insured for liability risks?                                                                                    YES        NO

 If “yes”, who by and what is your policy renewal date, current limit, deductible and premium?

Declaration and signature
We declare that the information and answers given in this form are true to the best of our knowledge and belief and that we have not mis-stated, mis-
represented or suppressed any material facts that might influence the assessment of the risk. At any time during the Period of Insurance, if
conditions, exposures or circumstances materially increase to that declared herein, we understand we are immediately required to advise
Underwriters. We also understand that completion of this form does not bind Underwriters or mean we will accept the Insurance Contract but, if
terms are agreed, it will form part of the Insurance Contract.
SIGNED:                                                                       POSITION:
NAME:                                                                         DATE:

                                                                   Page 3 of 4

Please detail the age, size, structure and location of the warehouse(s), (if additional space is required please attach a separate sheet).

Do you own or lease the warehouse?                                                                                       OWN          LEASE

Is the warehouse insured for physical loss & damage risks and are you a Named Insured on the policy?                     YES           NO

Is the warehouse TAPA (or other similar body) certified?                                                                 YES           NO

When was the facility last surveyed? Please attach a copy.                                                               YES           NO


What cargo do you store?

What is your responsibility for the cargo stored/handled?

Do you store cargo for more than 3 months at a time? If so, please provide details on a separate sheet

Please provide an estimated average and maximum value of goods stored at any one time:
(please include the currency)                                                                                          Avg:

What % of your total revenue is generated by warehousing operations?


Do all warehouses have sprinklers and fire detection systems?                                                            YES           NO

Is there easy access throughout the facility to the mains water supply?                                                  YES           NO

Is there easy access to an emergency pump or suitable reserve power supply?                                              YES           NO


Do your security precautions include 24 hour security guards?                                                            YES           NO

Are all the building, perimeter fences and gates always alarmed?                                                         YES           NO

Do your security precautions include CCTV?                                                                               YES           NO

Are security checks continually documented?                                                                              YES           NO

Please detail any other security precautions taken:


Do you have a property and equipment maintenance programme?                                                                YES          NO

Do you have a staff training programme?                                                                                    YES          NO

Are you compliant with the International Ship & Port Security Code (ISPS Code)?                                        YES       NO    N/A

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