Maritime Officers Legal Liability

P.O. Box 432; Hudson Falls, NY 12839 MARITIME OFFICERS LEGAL LIABILITY - APPLICATION FOR INSURANCE Please Email, Fax, or Mail your Completed Application and a copy of your license Global Marine Insurance Agency

Legal Name: Date of Birth :

Mailing Address: Phone Number:

Email:

Current License(s) Held:

Master Mate Deck Officer Chief Engineer Engineer

License Number (s): Years with Present License Grade: Date of License Expiration:

License Tonnage: License Geographic Scope:

Limit of Liability Requested : $500,000 $1,000,000 Background Information: Current Employer:______Years Employed______Previous Two Employers and Years Employed: Employer: ______Years Employed ______Employer: ______Years Employed ______Do you own or have an ownership interest in any vessels? Yes No Has your License ever been suspended or revoked? Yes No Have you ever been convicted of a felony? Yes No Have you ever had employment terminated by a maritime employer: Yes No Have you ever been convicted of a DWI or DUI? Yes No

If you checked “yes” to questions 1-4 above, please provide a brief explanation (attach additional pages as required):

Please List the primary areas you anticipate navigating for the upcoming year:

Please list any associations or unions of which you are a member:

Vessels You Currently Operate: Bulk Carrier Vessels Passenger of Ferry Vessels Container Vessels General Cargo Vessels Fishing Vessels Charter Vessels Tanker Vessels Tugboats / Pushboats Vessel Delivery or Instruction Oilfield Crew / Utility Vessels Other: (Please Describe)

APPLICANT’S SIGNATURE______DATE______SIGNING THIS APPLICATION DOES NOT BIND THE APPLICANT NOR THE INSURER TO THE INSURANCE, BUT IT IS AGREED THAT THE STATEMENTS CONTAINED IN THIS APPLICATION SHALL FORM THE BASIS ON WHICH THE POLICY IS ISSUED, AND IF COVERAGE IS ACCEPTED THIS APPLICATION SHALL BECOME PART OF THE POLICY OF INSURANCE. THE APPLICANT WARRANTS ALL SUCH STATEMENTS TO BE TRUE TO THE BEST OF THEIR KNOWLEDGE AND BELIEF. ANY MATERIAL MISREPRESENTATION OR NON-DISCLOSURE MADE BY THE APPLICANT WILL RESULT IN THE POLICY BEING NULL AND VOID . For more information please visit www.captainscoverage.com