Ship Repairers Application

Please complete as accurately as possible
 
Contact Information
*Name:
*E-mail:
*Phone:
*Address 1:
*State:
*Zip:

Company Information
Business Name:
*Describe Operations:
# of Employees:
Total Payroll:
Gross Reciepts:
Projected Reciepts:
Years In Business:

Workboat Information (If Applicable)
Do you own a workboat?:
Do you request P&I coverage for workboat?:

Prior Coverage
Prior Insurance Carrier:
Annual Premium:
Provide a Loss History If any:
Requested Coverage Amount:

Note: Fields with an * are required




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