General Information

Assured
Agent / Broker
ANNUAL GROSS RECEIPTS
Year Terminal Operations Stevedore’s Operations Wharfinger’s Operations Total Gross Receipts (All Operations)
ANNUAL PAYROLL
Year Terminal Operations Stevedore’s Operations Wharfinger’s Operations Total Annual Payroll (All Operations)
ANNUAL TONNAGE / THROUGHPUT
Year Annual Tonnage Annual Throughput (In Barrels) Other (Specify)
ADJACENT EXPOSURES
Docks Fleeting Locations Bridges Locks Dams Other (Specify)
Upstream
Downstream
Chemical Plants Refineries Ferry Landings Other (Specify)
Upstream
Downstream
MARITIME HAZARDS
TERMINAL OPERATIONS
DOCKING ACTIVITY
Type of Vessel Ave. Value (Tonnage) Max. Value (Tonnage) Ave. Length (In Feet) Max. Length (In Feet)
No Vessels @ Facility @ One Time Length of Stay of Vessel in Berth Length of Stay of Vessel @ Facility
Average
Maximum
Ocean Vessels Great Lakes Barges Other (Specify)
Tankers
Dry Cargo
CARGO HANDLING OPERATIONS
Type of Cargo Packing of Cargo Annual Tonnage / Volume Percentage Owned
SAFETY / SECURITY

INSURANCE DETAILS

Loss Experience: Please attach Five (5) years of ground up company loss runs.

The above information, and supplemental information enclosed, is true and correct to the best on my knowledge. I understand that I am not bound to accept the insurance and that underwriters are not bound to accept this risk.