iProtect Ph Life and Non Life Insurance Services

Non-Life Insurance Inquiry Form - Marine (Hull)

Part I

Name of Representative of Assured *

Name of Insurance Agent/Broker

Applicant

Name of Applicant and Designation *

Street Address

City

State

Country

Postal code

Mobile no. *

Email *

Part II

Specification of the Vessel (or provide Certificate of Ownership or Last Condition/Valuation survey report):

Name of Vessel *

Flag/Registry/Registry No. and IMO No. *

Place/Date of Built and Builder *

Gross Tonnage

Net Register Tonnage

Deadweight

Type of Vessel *

Length x Breadth x Depth

Propulsion Engine

Part III

Market Value *

Insured Amount *

Coverage Period *

Trading Areas

Type of Cargo Carried

Name of Mortgage (if applicable)

Part IV

Loss record - Please complete this schedule for all vessels owned and operated or managed during the past five years: (Vessel Name, Date of Loss, Amount Paid, Amount Outstanding)

Part V

Please attach of the following documents to this application/proposal form the following: 1. Security and Exchange Commission Registration 2. Vessel's Certificate of Ownership and Certificate of Registry 3. Last Condition/Valuation Survey Report 4. Management Flow chart

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