ABYC Marine Insurance Application

APPLICANT INFORMATION
Name of Company/Organization*
Main point of contact (full name)*
Email*
Phone
Applicant Web Site
Yrs. Experience as Business Owner
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Is your business owner operated?
- Yes
- No
Please indicate the form of your business
Other Business Form*
Do you have any employees?
- Yes
- No
Number of employees
Please enter a number from 1 to 4000.
Do you or your employees have current ABYC certifications?
- Yes
- No
Please list (Courses, Certifications and/or Accreditations)
Please describe your, or your employee's experiences and/or certifications.
What was your total payroll for last year? (USD)
What is your projected payroll for the next 12 months? (USD)
Has any insurance company declined, canceled or non-renewed your company’s policy or coverage during the past three years?
- Yes
- No
Please provide details about your company's declined, canceled or non-renewed coverage*

SHIP REPAIRER’S LIABILITY SUPPLEMENTARY QUESTIONNAIRE
Type of vessels worked on: (please provide percentages based on overall workload)
Ferro Cement
Steel
Fiberglass
Wood
Aluminum
Type of work: (please provide percentages based on overall workload)
Engine
Boiler
Hull
Electrical
Painting
Welding
No. of Vessels worked on last year
Average $ value of vessels
Maximum $ value of vessels

MISCELLANEOUS PROPERTY COVERAGE QUESTIONNAIRE
Marine Artisan’s coverage includes Miscellaneous Tools & Equipment Coverage at limits of $5,000 with a per item maximum of $1,000, subject to a $ 500 deductible. Please schedule all itemized equipment for limits in excess of the above;
Itemized equipment list
Please list the type of equipment and for each, the manufacturer, year and value

LOSS EXPERIENCE
List loss experiences for the past 5 years with amounts paid and outstanding (including uninsured losses).
Have you been in business for more than 3 years?
- Yes
- No
Have you claimed any losses in the past 5 years?
- Yes
- No
List loss experiences
Please list the date of loss, description of the loss and amount claimed.
If you have been in business less than three years, a resume demonstrating three years of experience in the trade is required. Please attach below.
Attach Resume
Accepted file types: pdf, doc, docx, Max. file size: 50 MB.

Owned Vessel(s)