<p> The Managers Thomas Miller P&I (Europe) Ltd. 90 Fenchurch Street London EC3M 4ST T +44 (0)20 7283 4646 F +44 (0)20 7621 9761 E [email protected] www.ukpandi.com APPLICATION FORM FOR NEW ASSURED</p><p>We hereby apply to enter the ship specified below for insurance in the Association in accordance with the Rules of the Association with which we agree to conform, and we further apply to become a Member of the United Kingdom Mutual Steamship Assurance Association (Bermuda) Limited (“UK Bermuda”) in accordance with the Bye-Laws of UK Bermuda and authorise you to enter our name in the Register of Members of UK Bermuda. We acknowledge that our attention is hereby drawn to Rule 5L and Rule 7 concerning the exclusion of the Insurance Act 2015 when it takes effect and to the extent that it applies to this insurance.</p><p>Name of Entered Ship Gross Tonnage Date Assured to be Entered From</p><p>Name and Address of New Member for Registration Interest (Owner, Affiliated to the Bareboat Charterer, Owner? etc.) (see definition under Rule 44)</p><p>Participating member of ITOPF (delete if not appropriate) Name and Address of New Co-Assured Members (see Rule 10 – Joint Owners) Interest (Owner, Affiliated to the Manager, etc.) Owner? (see definition under Rule 44)</p><p>Name and Address for Notices (see Rule 41 - Notices)</p><p>Email Address: Fax Number: VAT Status of Member If the above named Member is registered within the European Union for VAT purposes please give details below. Address of Member (or Agent) for EU VAT Registration EU VAT Number</p><p>Signature Capacity (Director, Authorised Agent, etc.)</p><p>Name (please print) Dated Company Name</p><p>The United Kingdom Mutual Steam Ship Assurance Association (Europe) Limited. Registered in England No.22215. Thomas Miller P&I (Europe) Ltd. Registered in England No. 2920387. Registered offices as above.</p>