APPLICATION FOR P&I COVER – PART ONE
(Complete all applicable questions)

Principal Insured *

Company Name:

Is this company publicly traded?

YES
NO

If Yes, on which Stock Exchange?

Trading Address:

If No, state name of principal shareholder (or owner) and any person owning more than 25% of the company. Principal shareholder / owner:

Country:

Others holding more than 25%:

Web address:

Telephone number:

Fax number:

Main Contact:

Contact Name:

Position:

Telephone:

Fax:

Email:

Is this person authorised to give instructions on behalf of the Principal Assured?

YES
NO

Second Contact:

Contact Name:

Position:

Telephone:

Fax:

Email:

Is this person authorised to give instructions on behalf of the Principal Assured?

YES
NO

* Organisation having commercial control of the ships to be entered.
Co Insured to be named in the certificate of entry **

(1) Company Name:

Trading Address:

Telephone number:

Fax number:

Capacity:

Co Insured is jointly liable for the payment of premium to the QITA.
Please confirm that this Co Insured has been made aware of their responsibility and has consented to being named by ticking the box and signing below.

Signed: --------------------------------------------------

(2) Company Name:

Trading Address:

Telephone number:

Fax number:

Capacity:

Co Insured is jointly liable for the payment of premium to the QITA.
Please confirm that this Co Insured has been made aware of their responsibility and has consented to being named by ticking the box and signing below.

Signed: --------------------------------------------------

(3) Company Name:

Trading Address:

Telephone number:

Fax number:

Capacity:

Co Insured is jointly liable for the payment of premium to the QITA.
Please confirm that this Co Insured has been made aware of their responsibility and has consented to being named by ticking the box and signing below.

Signed: --------------------------------------------------

Insurance History

the prospective Insured or any prospective co-Insured previously been denied coverage by any underwriter?

YES
NO

Has the prospective Insured or any prospective co-Assured ever had a marine policy terminated by an insurer?

YES
NO

Have any restrictive terms or warranties been imposed on the prospective Insured or any prospective co-Insured by his current marine liability / P&I insurers?

YES
NO

If you have answered Yes to any of the above questions, please give details below:

Company History / Structure

Please provide a brief history of the company and / or its principal shareholders / owner. Please provide details of the company’s operating experience and loss record with previous marine liability / P&I insurers for the last 5 years. Please provide details of the company hierarchy and structure.

Has the prospective Insured or any prospective co-Insured ever declared bankruptcy (voluntary or otherwise), sought the protection of a court because of insolvency, or is currently in bankruptcy?

YES
NO

Declaration :

Name:

Signature/Stamp:

Date: