Apollo General Insurance Agency, Inc.
PO Box 1508, Sonoma, CA 95476
License # 0606980
Ocean Marine Application
Marine Commercial Liability Supplementary Information for
Shiprepairers Legal Liability
(This is not a Binder)
Name of Applicant /Producer Name and Address
Address – Number and StreetCity State Zip
Location of Yards
Total Number of Years in Business
Nature of Repair Operations
Broiler ______% Engine ______% Hull ______% Electrical ______% Painting ______%
Welding ______% Gas Freeing ______% Number of Gas Freeing Operations (Annually) ______
If Applicant Engages in Gas Freeing Operations, is Certification Conducted by a Marine Chemist prior to Hot Work? Yes No
Does Applicant Operate Yard Vessels, Drydocks, Marine Railways or Graving Docks? Yes No
If Yes, Please Explain:
Vessels Repaired:
Value Size
Type (Percentage) Description Average Maximum Average Maximum
Commercial Vessels _____% ______$______$______$______$______
Private Pleasure _____% ______$______$______$______$______
Government/Navy _____% ______$______$______$______$______Other _____% ______$______$______$______$______
Average and Maximum Number of Vessels in Yard at any one Time _____Number of Vessels Repaired in the Last 12 Months and Estimated Next 12 Months
Last 12: ______Next 12: ______
Percentage of Work Subcontracted: ______%
Is Subcontracted Work Accompanied by a:
Hold Harmless / Indemnify Agreement? Yes No Wavier of Subrogation? Yes No
Are Certificates of Insurance Required? Yes No What Limits: $ ______
Approximate Percentage of Repair Conducted Outside Yard: ______%
Locations:Does Applicant Engage in Building, Rebuilding or Conversion of Vessels: No Yes
If Yes, Please Provide Details and Include Vessel Construction Supplemental Information:
Does Applicant Enter into Contractual Agreements Other Than Those Normal to the Industry? No Yes
If Yes, Please Provide Details and Copies of Contracts:Gross Revenue Last 12 Months: Commercial: $______Navel: $______
Gross Revenue Next 12 Months: Commercial: $______Navel: $______
Current Insurance Carrier:
Current Premiums (i.e. Deposit and Adjustment Rate):
Limit of Liability Required:
$ / Deductible Required:
$
Proposed Date of Attachment:
S.R.L.L. and Marine Comprehensive Liability Loss Record Prior Five Years (Gross Claim Prior to Deductible):
Type of Loss
/ Date / Location ofAccident / Details / Gross Amount Before Any Deductible /
Location
Open / Closed$
$
$
$
$
$
Has Any Policy or Coverage Been Declined, Cancelled or Nonrenewed During the Past Five Years? No Yes
If Yes, Provide Details:Describe Yard and Building Fire Protection:
Describe Yard Security:
Are Revenues Generated From Other Than the Marine Operations Described Above? No Yes
If Yes, Provide Details:Does Applicant use the Employee Leasing Services and/or Temporary Workers? No Yes
If Yes, are There:
Hold Harmless / Indemnify Agreements in Place in the Applicants Favor? Yes No
Waiver of Subrogation? Yes NoAre Certificates of Insurance Obtained? Yes No
What Limit: $ ______
Contact and Phone Number to Arrange a Yard Inspection:
Name: ______Title: ______Phone #: ______
Remarks:
Any Person Who Knowingly And With Intent To Defraud Any Insurance Company Or Other Person Files An Application For Insurance Containing Any False Information, Or Conceals For The Purpose Of Misleading, Information Concerning Any Fact Material Thereto, Commits A Fraudulent Insurance Act, Which Is A Crime. (Applicable To New YorkState Only.)
Signing This Application Does Not Bind The Applicant To Purchase The Insurance Or The Company To Accept The Risk, But It Is Agreed That This Application Shall Be The Basis Of The Contact Should A Policy Be Issued.
Applicant Signature: / Company Title: / Date:
Producer Signature: / Company Title: / Date:
Additional Comments: