Protection Indemnity Proposal Form (Page 3 of 3) in pdf

Protection Indemnity Proposal Form Page 3

PROTECTION & INDEMNITY

PROPOSAL FORM

Claims cont..

Year

Claim Amount

Claim Details

Details of

Insurances:

Previous Insurance - In respect of this, or any other vessel owned or commanded by you, has

any Insurer:

(a)

Declined cover

Yes:

No:

(b)

Cancelled or declined to renew cover

Yes:

No:

(c)

Imposed loadings, restricted terms or

Yes:

No:

additional premiums

If yes, please give details:-

Disclosure of Material Facts

You must disclose all material facts, not only those covered by specific questions in this Form.

Material facts are those which an insurer would regard as likely to influence the acceptance and

assessment of your application. A good example is claims experience. If you fail to disclose a

material fact, your insurance cover could become completely void. If you are in doubt as to

whether any fact is material, you should disclose it.

Signed:………………………

Capacity: (i.e. Director etc):……………………….

Date:……………………

Protection Indemnity Proposal Form Page 3