Paul Lynch & Associates, Inc.
3388 NE Sugarhill Avenue, Stuart, FL 34994
Tel: 772-232-9371 / FAX: 772-232-2522

Ship Repairer's Liability Insurance Application
 

When filling out this application, all questions must be answered completely, if a question is not applicable to the operations of the company, please state "N/A".  If the answer is none, state "NONE". Leave no space blank.
1. Name of Applicant:
2. Full Address:
Address:
Address:
City: State: ZIP:
3. Location of Yard(s):
4. Describe property adjacent to the yard:
5. Breakdown of repairs by the following types of work:
Hull repair: % Machinery: % Hydraulics: %
Welding: % Electrical: % Gas Freeing: %
Boiler: % Painting: % Other: %
6. If GAS freeing operations are carried out:
(a) State number of vessels gas freed last year:
(b) Does the applicant employ a full-time gas free chemist: Yes No
(c) Does the applicant employ an outside sub-contracted chemist: Yes No
7. Does the applicant strictly adhere to the rules & regulations of the national fire protection agency applicable to work on vessels which have carried combustible liquid in bulk, as fuel or cargo:
Yes No  If No, Please explain:
8. Yard Facilities:
(i) Dry-docks:
Name Year Built Size Construction Capacity Last Certification Date
(ii) Marine Railways:
Name Year Built Size Construction Capacity Last Certification Date
(iii) Repair Piers:
Name Year Built Size Construction Capacity Last Certification Date
9. Type of vessels worked on:
US Navy: % Commercial "Blue Water": %
Marad: % Commercial "Brown Water": %
Pleasure Craft: % Other: % Specify:
10. Give details of any contractual liability limitation agreements:
11.
(a) No. of vessels repaired in yard last year: (b) No. of vessels repaired outside yard last year:
(c) Avg. Value of vessel: (d) Max. Value of vessel:
12. Other work (Work other than ship repair):
Gross receipts of other work:
Give full details:
13. "Downstream" Operations:
What is the percentage of work carried out away from the applicant's premises where the vessel, craft, or equipment being worked on may be considered in someone else's custody and control? %

What is the nature of this "Downstream" work?
Where is the work carried out?

14. Give details of owned, hired or leased watercraft, docks or floats used during repair operations:
Vessel Year Built Dimensions GRT

Signing this application does not bind the applicant nor the insurer to the insurance, but it is agreed that the statements contained in this application shall form the basis on which this policy is issued, and the applicant warrants all such statements to be true to the best of its knowledge and belief. This application will be appended to the policy.

This form will be electronically submitted to our offices, we will complete an actual application and contact you to confirm the information contained herein and to get your signature. Please provide a phone, fax, or email address so that we may contact you regarding this information.
Applicant's Signature: Dated:
Applicant's Name: Title:
Phone:
FAX:
E-Mail