Paul Lynch & Associates, Inc.
3388 NE Sugarhill Avenue, Stuart, FL 34994
Tel: 772-232-9371 / FAX: 772-232-2522
Maritime Employer's Liability Application
 
1.A) Full Name of Assured: 

Full Address of Assured:
Address Line 1: 
Address Line 2: 
City:    State:     ZIP: 

1.B) How many years has Assured been in operation:
2) Full details of Assured's overwater operation:
3) Total number of employees:
4) Total Gross annual payroll:
5) Total number of employees exposed overwater per annum:
6) Maximum number of employees exposed overwater at any one time:
7)
Gross overwater payroll split for last 12 months:
A) Jones Act:
B) L.S.H.W.A:
8)
Gross overwater payroll split for next 12 months:
A) Jones Act:
B) L.S.H.W.A:
(Underwriters reserve the right to audit the Assured's accounts at any time, at Underwriters expense)
9) Does the Assured engage in any diving operations: Yes  No
10) Does the Assured own and/or operate any watercraft*?  Yes  No
Please provide full details:
11.A) Do/will employees work on or from or have any connection with watercraft* during the policy period:  Yes  No
11.B) Is watercraft* work done dockside and/or in Assured's yard only:  Yes  No
11.C) If shipbuilding/shiprepair do employees do trial trips, if so how often and time involved per annum:
Yes  No   Time involved:
11.D) If any employees work on or from or have any connection with watercraft* away from dockside, does any one employee spend more than 20% of their time working on or from or in connection with watercraft*: Yes  No
11.E) Does/will the Assured have jobs of short duration overwater: Yes  No
If so, please provide the maximum percentage of time during the job that any one employee will be working on or from or in connection with watercraft*:
11.F) Do/will employees keep any of their tools or equipment on watercraft*: Yes  No
12) Full 5 year death/injury/illness record including any reserves (including any claim/incident arising overwater reported to Workers' Compensation and/or L.S.H.W.A. Insurers):
13)
A.  Present Insurers:
 B.  Expiring date:
C.  Limits carried:
 D.  Limit required:
E.  Premium charged:
*Note: The definition of a watercraft includes any vessel or special purpose structure other than a fixed, permanent platform which is capable of navigation either under its own power or being towed. Jack-ups, semi-submersibles, and/or barges are deemed to be watercraft for the purpose of the above questions.

IMPORTANT:

THIS QUESTIONNAIRE IS TO BE COMPLETED AND SIGNED BY THE ASSURED AND WILL FORM PART OF THE MARITIME EMPLOYER'S LIABILITY POLICY ISSUED.

THE PREMIUM CHARGED AND THE CONDITIONS OF THIS POLICY ARE BASED UPON THE INFORMATION PROVIDED IN THIS QUESTIONNAIRE. ANY OPERATIONAL AND/OR PHYSICAL CHANGES IN THE NATURE OF THE ASSURED'S OVERWATER OPERATION DURING THE POLICY PERIOD WHICH MATERIALLY CHANGES OR ALTERS IN ANY WAY THE INFORMATION CONTAINED IN THIS QUESTIONNAIRE MUST BE IMMEDIATELY BE ADVISED TO THE UNDERWRITERS. ANY CHANGES ADVISED WILL BE ASSESSED BY THE UNDERWRITERS TO ENABLE THEM TO DECIDE WHETHER THEY ARE PREPARED TO CONTINUE TO PROVIDE THIS COVERAGE AND AT WHAT TERMS. FAILURE TO COMPLY WITH THIS REQUIREMENT WILL VOID THE POLICY

Signature of Assured:  
Dated:
Print Name:
Contact information:
Phone:
FAX:
E-Mail:

This form will be submitted to our offices, the actual form will be filled in by our staff and we will contact you to obtain your signature and to clarify any other information we may need.