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North Star Marine Insurance Services, LLC

59 Main Street, Unit #1

Fairhaven, Massachusetts 02719

774.202.2751 Phone 774.202.3764 Fax

  

Application for Marine Insurance

Section I – Assured Information

Fleet Affiliation

Vessel Name:

Named Assured:

Address:

Phone/Fax/ Email:

Business Type:

Section II – Other Assured Information

Additional Assured:

Address:

Loss Payee:

Address:

Mortgage Holder:

Address:

Mortgage Amount:

Section III – Vessel Information

Vessel Type:

Official Number:

Estimated Market Value:

Estimated Replacement Value:

Date of Last Survey:

By:

Year Built/Modified:

Shipyard and location:

Year Rebuilt?

Year Converted?

Design?

Construction:

Beam:

Length:

Draft:

GRT:

Classed:

Engine Type:

Model No.:

Hours:

Fuel :

Stability Test Date:

By:

North Star Marine Insurance Services, LLC

59 Main Street, Unit #1

Fairhaven, Massachusetts 02719

774.202.2751 Phone 774.202.3764 Fax

  

Application for Marine Insurance

Please include the total number of people on board the vessel including captains and owners/operators who you want to be covered by Protection &Indemnity Insurance (excluding Observers).

Section IV – Operations:

Month

# of Hired Crew

# of Processors

Area of Operation

Operation

January

February

March

April

May

June

July

August

September

October

November

December

Observer/Owner Coverage:

Number of Observers on Board:

Estimated Dates on Board:

Is Vessel Operated by Owner?

Yes

No

Is Coverage desired by Owner?

Yes

No

Operators:

Captain’s Name:

Relief Captain #1 Name:

Phone:

Phone:

Birth Date:

Birth Date:

Licenses (list):

Licenses (list):

Years Experience:

Years Experience:

Fishing Experience:

Fishing Experience:

Vessels Operated:

Vessels Operated:

Captain’s Loss History:

Captain’s Loss History:

Section V – Loss Information – Last Five (5) years required

Protection & Indemnity Claims

Date of Loss

Type

Status

Paid

Reserved

Total Claim

Hull & Machinery Claims

Date of Loss

Type

Status

Paid

Reserved

Total Claim

North Star Marine Insurance Services, LLC

59 Main Street, Unit #1

Fairhaven, Massachusetts 02719

774.202.2751 Phone 774.202.3764 Fax

  

Application for Marine Insurance

Section VI – Coverage Required:

Hull & Machinery

Skiff

Policy Dates:

Policy Dates:

Amount Required:

Limit Required:

Deductible:

Deductible:

Increased Value

Gear

Policy Dates:

Policy Dates:

Limit Required:

Limit Required:

Deductible:

Deductible:

Protection & Indemnity

Excess Protection &Indemnity

Policy Dates:

Policy Dates:

Limit Required:

Limit Required:

Deductible:

Breach of Warranty

War Risk

Policy Dates:

Policy Dates:

Amount Required:

Limit Required:

Pollution

Accidental Death & Dismemberment

Policy Dates:

Policy Dates:

Limit Required:

Amount Required:

Cargo*

Other

Policy Dates:

Policy Dates:

Amount Required:

Amount Required:

*If Cargo is desired, please request separate application

Section VII – Trading Warranty

Section VIII – Attest

Has insurance ever been cancelled or refused?

YES

NO

I HEREBY ATTEST that the information contained in this application is correct and complete to the best of my knowledge. I understand this is an application and not a binder of insurance and is not to be construed as such.

Signature of Assured

Date

North Star Marine Insurance Services, LLC

59 Main Street, Unit #1

Fairhaven, Massachusetts 02719

774.202.2751 Phone 774.202.3764 Fax

  

Skipper’s Questionnaire

To be completed by the skipper as a supplement to the application form.

1. Name of Skipper:

Vessel to be operated:

Address:

Phone:

Email:

2. Date of Birth:

3. How long have you been fishing?

4. Certificates/Qualifications held:

5. Details of previous vessels owned/operated/crewed on in the last five years:

Vessel

Home Port

Size/Type of Vessel

Position Held

Dates

6. Claims/loss record of Skipper for the last five years on all vessels operated, whether insured or not:

Year

Details of Loss

Amount Involved

Insurer

Amount of Claim

7. Have you AT ANY TIME been involved in any major damages/total losses on any vessel whether insured or

Not, and if so, give brief details, including date, costs, and names of vessels involved:

8. I hereby declare that the particulars and answers given in this questionnaire are in every respect true and

correct and that I have not withheld any information which could influence the decision of the company in

regard to its acceptance.


FAILURE TO DISCLOSE ALL RELEVANT FACTS MAY INVALIDATE THE POLICY.

Signed:

Date:



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