Wharfingers Supplementary Application

Insured Location(s): 1. 2. 3. 4. 5. Facilities Description (Dimensions/age/construction/mooring,etc.) for each of the locations above 1. 2. 3. 4. 5. Water depth (per loc): Number of berths (per loc): Maximum draft of vessels calling (per loc): 1. 2. 3. 4. 5.

Type of vessels handled (indicate number per year):

Self-Propelled Dry Cargo ______Tankers ______

Barges Dry Cargo ______Tank ______Other ______

Annual Number of Dockings last 5 years: (total number of vessel calls)

20______20 ______20______20______20______

Annual Number of Vessel Days last 5 years: (total number of days - all vessels)

20______20 ______20______20______20______

Average value of vessels: ______

Are vessels inspected and signed for when picked up and delivered?

Vessels are moved by: Hand______Power Winch______Other______

Describe traffic passing to and from off your facility:

No part of this document may be reproduced, published or posted without the permission of The Hartford. Page 1 of 2 Who is responsible for mooring vessels at your facility?

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)? ______

Describe loading and unloading equipment including type, capacity and power:

Describe your procedures in the event of a breakaway:

Number of hours watchman is on duty ______Is clock punched ______

Is facility lighted? Fenced?Describe public access:

Are fueling services provided? Types of fuel handled:

Who is responsible for bilge inspection and pumping if needed?

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

Number of fire hydrants at insured location? ______

Number of fire extinguishers at your facility ______Size______Kind______

Current Premiums (i.e. Minimum & Deposit and adjustment rate):

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

No part of this document may be reproduced, published or posted without the permission of The Hartford.