Oceanic Underwriters Ltd

O C E A N I C U N D E R W R I T E R S Page 1 of 2 COMMERCIAL VESSEL APPLICATION

Name of Owner(s): Occupation: Address:

VESSELS: No. of Year Manufacturer Vessel Type Construction Length H.P. Passengers Insured Value Built (If applicable)

OPERATING AREA: Where are the vessels moored? Where are the vessels laid up and out of commission if applicable? Number of Years in Business: Details of Operations: Does the insured operate all year round? Yes No If not, please provide details of when the insured operates:

Years As Size & Type of Name of Operators Birth Date Boating Education / Courses Operator / Crew Vessels Operated

Rev. Jan 23, 2015 O C E A N I C U N D E R W R I T E R S Page 2 of 2 COMMERCIAL VESSEL APPLICATION

Loss Experience: Have you or any operator listed had any losses or accidents involving vessels? Yes No

If yes, please complete the following: Date of Loss Cause Amount 1. 2. 3. 4.

COVERAGES: Amount / Limits of Insurance Required (not to exceed current market values) (a) Hull & Machinery $ (b) Protection & Indemnity $

INSURANCE REQUIRED from: to:

LOSS PAYEE: Address:

CURRENT INSURERS: CURRENT TERMS AND CONDITIONS: REASON FOR CHANGE:

PLEASE READ BEFORE SIGNING APPLICATION: This application will be incorporated in its entirety into any relevant policy of insurance where Insurers have relied upon the information contained herein. Any misrepresentations or concealment in this application for insurance, will render insurance coverage null and void from inception. Please therefore check to make sure that all questions have been fully answered and that all facts material to your insurance have been disclosed, if necessary by a supplement to the application. A consumer report containing personal, credit, factual or investigative information about the applicant may be sought in connection with this application for insurance or any renewal, extension or variation thereof. Signing this form does not bind the Applicant to purchase the insurance or the Insurer to accept the risk, but it is agreed that tis form shall be the basic of the contract should a policy be issued.

AGENT / BROKER: EMAIL ADDRESS: SIGNATURE OF OWNERS: DATE:

** Email application and attachments to - [email protected] ** Western Canada - T 604.689.1501 F 604.689.5663 Ontario & Atlantic Canada - T 519.850.1610 F 519.850.1614

Rev. Jan 23, 2015