16th May, 2008 | 14:24:53 BST

Proposal Forms

Marine Surveyors Form

ITIC Ltd, International House, 26 Creechurch
Lane, London EC3A 5BA.
Tel. +44 (0)20 7338 0150 Fax +44 (0)20 7338 0151
E-mail ITIC@thomasmiller.com
Website www.ITIC-insure.com

[Download this form in Word 6/95 format]

Company Name:

Address:

Telephone:

Fax:

E-mail:

Insurance Broker:

1. General Information:

1.1

Date company established:

1.2

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

1.3

Total number of staff (including directors, surveyors and office staff) engaged in providing the services to be insured:

1.4

Please list the names, professional qualifications and number of years experience of your surveyors, including working partners and directors:

1.5

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

2. Services:

2.1

Please estimate your gross annual fees and indicate the percentage from each category:

Gross annual fees - work undertaken (Last year)

Gross annual fees - work undertaken (Previous Year)

Gross annual fees - work undertaken (Forthcoming Year) (estimated for new and existing practices)

Hull underwriters: (%)

Ship owners/charterers or their P&I clubs: (%)

Cargo underwriters: (%)

CMR (road transport) underwriters: (%)

Non-marine underwriters: (%)

Quality control, Superintendence etc.: (%)

Other (brief description):

2.2 Please state

(estimated for new and existing practices)

Gross fees paid to sub-contractors - (Last year)

Gross fees paid to sub-contractors - (Previous Year)

Gross fees paid to sub-contractors - (Forthcoming Year)

2.3

Please name the principals for whom you regularly act:

2.4

Do you approve towage arrangements for ships, oil rigs, barges, offshore production or any other craft? yes no

2.5

If you have answered yes, please indicate what percentage of your annual fees relates to towage approval works. (%)

3. Trading conditions and documentation:

a) Do you use standard trading terms and conditions? yes no

If "Yes" - please provide a copy †

b) Do you have any contracts or agreements with specific clients? yes no

If "Yes" - please advise the names of these clients,

and provide a copy of the contract or agreement: †

4. Claims history:

Have any claims been made against you, or have there been any circumstances likely to give rise to a claim made against you in the last five years? yes no

If "Yes", please give details:

5. General declaration:

Has any insurer:

a) declined to insure you? yes no

b) cancelled your insurance? yes no

c) refused to renew your insurance? yes no

d) imposed special terms? yes no

If "Yes", please give full details:

6. Declaration:

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 misstated or suppressed any material facts that might influence the Club's assessment of the risk. We also understand that completion of this form does not bind either the Club or ourselves to accept this insurance but, if terms are agreed, it will form part of our contract with the Club.

This proposal form must be completed by a person who is authorised to bind the proposer.

Name:

Position in company:

Date:

† The total aggregate size of all your attached files should not exceed 1Mb.

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