MARINE INSURANCE PROPOSAL/KYC FORM

Value (Est. Annual Limit):

Limit per Conveyance:

Cover Type-Institute Cargo Clauses "A","B", or "C"

MARINE HULL DETAILS ONLY:

Name of Vessel:

Vessel Type:

Value (Hull & Machinery):

No. Of Crew:

Year of Construction:

P & I:

What is the Vessel used for?

COMPANY DETAILS

Date of Registration:

Incorporation No.:

Names/Addresses of Company Directors:

Name:

Address:

DOCUMENTS/INFORMATION TO BE SUBMITTED: * Please provide photocopies and bring along the original documents for confirmation.

1) Certificate of Incorporation/Registration: (*)

2) Proforma Invoice: (*)

3) Form CO2:

4) Form CO7:

5) Copy of Authorization to Operate from Relevant Regulatory Bodies:

6) Utility Bill: (*)

7) ID Card: (*)

INSURANCE/LOSS HISTORY

Have you Ever been insured for the Type of Cover Proposed?
YesNo

If Yes, Please Give Name of Insurer:

Has Any Insurance Company or Underwriter Ever?
Cancelled your Policy?Declined to Insure you?Refused to Renew your Policy?Imposed any Special Terms?Declined any Claim

If the Answer to any of the list is Yes, Please Give Details:

Have you Suffered Loss in the Last Three Years

YesNo

Date of Loss (If Yes):

Nature of Loss:

Amount of Loss:

Name of the Insurance Company with which the Claim was Made:

DECLARATION: I/We, hereby declare that the above particulars and answers are true and complete in every respect, and that no information has been suppressed or withheld. I/We further declare that if such statements and particulars are in the writing of any person other than myself/ourselves such person shall be deemed to have been my/our agent for the purpose of filing the form.

Signature:

Date:

Agent/Company Representative