Stevedores Supplementary Application

Locations (physical address of operations):

Please advise the following for each type of cargo separately:

Tonnage handled Tonnage estimated Method of Type of Cargo last 12 months next 12 months handling

General Break-bulk Cargoes ______Refrigerated/chilled Cargoes ______Bulk Grain ______Coal/Bulk Ores ______Liquid Chemicals ______Bulk Oils ______Scrap Metals ______Heavy Lift Cargoes ______Containerized ______Automobiles ______Explosive, Flammable or Toxic Cargoes ______Machinery ______

Total Annual Gross Receipts derived from Stevedoring operations last 3 years: 20_____ 20_____ 20______

Are revenues generated from other than stevedoring operations? Yes No If yes, provide details:

Total Annual Gross Receipts derived from other than stevedoring operations last 3 years: 20_____ 20_____ 20______

of 2 For liquid cargos in bulk, are you responsible for hook-up of pipes (a) Aboard Ship? Yes No (b) At Shoreside connection/tank farms? Yes No

Are you responsible for properly & safely stowing as well as loading or unloading cargos? Yes No

Do you perform lighterage operations? Yes No If yes, (a) How far offshore are the lightered ships? ___ miles (b) What kind of cargos are involved?

Do you own or lease the terminal you service? ______If leased, who is responsible for maintaining the property? ______

Is cargo handling equipment owned or leased? ______If leased, are you responsible for complying with

Mfg. recommended maintenance (or is there a maintenance service contract)? ______

If Ship’s handling equipment is used, approximately what % of the time? ______

Who operates the ship’s handling equipment? ______(Stevedores or ship’s crew?) ______

If ship’s crew operate the equipment, do they do so under your direction? Yes No

Municipal or volunteer fire department?______Distance from insured location?______

Number of fire hydrants at insured location? ______# of extinguishers?______