Sarnia Marine Insurance Brokerage Co. Ltd.

Hull and Machinery Insurance Proposal Form

Vessel Details

Trading Area

No.	Where does the vessel trade?	Regular Linder Trade or spot Market?	Cargo – owned or belongs to third parties	What Cargo / trade do you anticipate?

Experience
What experience does your company have in running these types of vessels?

Please provide CV’s of main key persons (email these seprately to sarnia@sarniamarine.com)
Claims and Insurance
Have you got original claims record for your ownership/management
Please provide full details of any losses that occurred during the past 5 years
Please state when the above figures were last reviewed
Who is your current insurer?
General Information
Period of Cover required?
When did the vessel pass her last special survey?
Name of Mortgagee Bank (If Applicable)
Collision Liability covered under your H&M Policy 3/4^ths 4/4^ths Excluding collision liability
I hereby state that all the information that I provided on this form are correct and that Sarnia Marine Insurance Brokerage Co. Ltd contact me for more information I Agree