HULL INSURANCE PROPOSAL FORM

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Proposal no. Policy no.

Individual Company National ID Card Registration Certificate

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Occupation: Nature of Business: Work Permit Passport

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Company/Office/Applicant’s Name: ID No.

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Date of Birth: Male Female Reg No.

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Permanent Address (as in ID card): Contact Name:

(cSwtogWv iawguDWk IDwa) csercDea ImiaWd cnwn egWhIm EhejcnwLug

Current Address Nationality:

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House/Building name: Contact No:

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Road: District: Email:

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Postal Code: Atoll,Island: Fax:
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Mortgagee: : cnwn egcaetWrwfea wmwn Wviawferuk unuhwr

Name of Vessel: : cnwn egudnwLua

Hull/Reg. No. : urwbcnwn IrcTcsijwr

Period of Insurance: : utwdcaum WvcnunEb cnwruk cscnerwauxcnia

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Engine Type: Engine Brand & Model: Engine Horse Power: Engine no. Engine Original Purchased Year
Outboard
Inboard

Type of Material used in Hull: :ctwvWb irukcnunEb cnwncnwb udnwLua

If the type of material used is “Wood”, please specify the type of wood: :ctwvWb egIDukwl

Insured Value: Hull value: Engine value: Machinery & Equipment value: :ugwa WvcnunEb cnwruk cscnwrwauxcnia

Type of Insurance Cover Required:

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Hull and Machinery Passenger Liability Protection & Indemnity
Total loss only Limit of liability: Limit of liability:
Full Cover No. of passengers:

Trading Limits: : cawtubWsih enWruk cnunEb udwLnua

1. When was the vessel surveyed and by whom?

2. What work is the vessel engaged upon?

3. What cargoes will be carried? (Please give details)

1-2
4. Has the vessel been insured before? Yes No
(a) Name of the Insurer

(c) Nature of cover granted

(b) Whether the insurance is still current

5. Has any insurer in respect of the vessel you wish to insure or any other vessel you have had any interest in:

(a) Declined/ Refused to insure you? Yes No

If yes, please give full details

(b) Increased your premium on renewal? Yes No

If yes, please give full details

6. Have you ever made a claim upon an insurer?

Yes No
If yes, please give full details

7. Has the vessel recently been overhauled or have any major repair been undertaken? Yes No
If yes, please give full details

8. Please state the Captain’s claim history for the past 5 years

9. Please state the Management’s / Operator’s / Owner’s claim history for the past 5 years

DecIaration: I/We confirm that the above answers, statements, patticulars and additional information are true to the very best of my/our knowledge
and belief. I/We also confirm that I/We have disclosed all information and material facts that may alter the insurer’s view of the risk. or affect their
assessment
. of the exposures they are covering under the Policy. I/We agree that this proposal shall be basis of the contract and part of the insurance

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iaWncnemuDnwguLwa / iaWDnwguLwa iaWNcnufcnuk cscnerwauxcnia .evemIfcaok WscaiH cnemuDnwguLwa / uDnwguLwa iaWtWrwf Wruk rwauxcnia utWmUluAwm wmwhiruf ELug iaWkwtcawtcnwk Enemih cnuSwd egIsilop ,iaWaIsilop cscnerwauxcnia
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Signature: Date:

Documents required with the Proposal: itekwt EhejcnwLwawSuh ukea iaWmOf

Seaworthiness certificate / Survey result slip Vessel’s registry copy ID. Card/Company’s registration copy
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Passenger Carrying Certificate Load Line (if applicable) Fishing Licenese (if applicable)
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Bank use only

Rate: Premium: Agent’s / Broker’s Name:

THIS INSURANCE WILL NOT BE IN FORCE UNTIL THE PROPOSAL HAS BEEN ACCEPTED BY THE COMPANY
(Acceptance of Proposal means Insurance policy issued and premium collected)

BANK OF MALDIVES 2-2