Darlow Marine Insurance P&I/H&M APP
Please complete as best you can and try not to leave any blank fields. If you are unsure how to answer a question try using "unknown" or "n/a" or "TBA" or "TBD"
Shipowner:
Company name
Your answer
Address:
Address
Your answer
Phone #:
Telephone number
Your answer
Fax #
Telephone number
Your answer
E-mail:
E-mail address
Your answer
Operator/Manager's name:
Company name
Your answer
Address:
Street address
Your answer
Phone #:
Telephone number
Your answer
E-mail:
E-mail address
Your answer
Years in Business
Years in business of either the owner or the operator (preferably whomever has more experience)
Your answer
Vessel name:
Your answer
Vessel registration #
Your answer
Country of Registry
Your answer
IMO#:
Your answer
Call Sign
Your answer
Year built:
Your answer
Construction
Where was vessel built
Your answer
Hull Type
Single or Double hulled
Hull Material
Steel, Aluminum or Wood
Home Port / Marina Address
Your answer
Flag:
Your answer
Classification society:
Your answer
Length
Your answer
Breadth
Your answer
Draft
Your answer
Type of vessel:
Barge, General, Ro-Ro, Tanker, Tug, etc..
Your answer
Purchase Price
Your answer
Date Purchased
Your answer
Protection & Indemnity limit of liability:
P&I limit of liability requested in USD ($)
Your answer
Hull & Machinery value:
Vessel hull value in USD ($)
Your answer
If pollution coverage is needed, please provide limits required / requested.
If unknown, state "same as P&I" or "as recommended" or "as required"
Your answer
Is a Certificate of Financial Responsibility (COFR) needed?
*Vessels greater than 300 gross tons and vessels of any size that are lightering or transshipping oil in the Exclusive Economic Zone (EEZ) are required to comply with the COFR regulations in order to operate in U.S. waters.
Is a Blue Card needed?
All ships over 1,000 GT registered in a State party or entering or leaving a port or terminal in the territory of a State party are required to have a Bunkers Convention Certificate "Blue Card" as part of the International Convention on Civil Liability for Bunker Oil Pollution 2001 (the “Bunker Convention”). Also required under the bunker convention is War Risk insurance on standard terms, with a separate limit for P&I liabilities up to the limit of the value of the ship. The required limit for P&I liabilities under that policy is the proper value of the ship, deemed not exceeding US$100 million.
If Blue Card is needed, please provide the mailing address of the party state member port authority where the Blue Card needs to be sent to
Your answer
Additional coverages
Crew (# of crew & nationality):
If coverage needed for crew, please include the # of crew members & their nationalities
Your answer
Passengers (Max. # of passengers):
If coverage needed for passengers, please include the maximum # of passengers
Your answer
GRT:
Gross Registered Tonnage
Your answer
Deadweight:
Your answer
NRT:
Your answer
Vessel Speed
Your answer
Type of cargo carried:
Your answer
Navigation limits / Trading area:
Your answer
Make & quantity of Engine(s)
Your answer
Engine(s) Model #
Model # for each Engine
Your answer
Horse Power (total)
Your answer
Type of Fuel:
Fire extinguishers:
Name of present or last insurer:
Your answer
5 Year loss history
(Date of loss, Vessel name, Description of incident, Amount paid by company, if any? If no losses, please specify 'No losses')
Your answer
Additional comments:
Your answer
Signature of applicant:
Your answer
Title
e.g. Vessel owner, operator, representative, President-CEO-Director of <Company Name>
Your answer
Date of this submission
MM
/
DD
/
YYYY
Email
The quotation will be sent to this email.
Your answer
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