Stevedoring Liability Part I. You and Your Company 1. Name of Company: 2. Office Address: 3. Established: 4. Principal Owners / Shareholders 5. Principal Company Officers and relevant experience: 6. Contact for Insurance Matters: Phone D/L: T/L: Mobile: Fax: E-Mail: Secretary / Assistant: 7. Estimated Total Gross Receipts (all activities) or number of TEUs of the Company for next 12 months Page 1
Part II Your Stevedoring Operations 1. Please describe what stevedoring services are provided by your Company, (example: loading, unloading, forklift operations, cranebarge operations, lightering operations, etc.): 2. Examples of main types of goods / cargos handled: 3. Port where stevedoring services are provided: (Please give exact pier / warehouse number if working inside large port area) 4. Examples of Major Clients / Principals: 5. Estimated maximum value of cargo that may be handled any one shipment: 6. Is it possible to estimate the total value of all shipments handled by your Company in one year? If so, please state value: Page 2
7. Types of vessels usually served and estimated maximum size: 8. Number of employees involved in all stevedoring/cargo handling operations: 9. Please describe vessels / equipment used in your stevedoring operations (and state whether vessels / equipment are owned / leased by you or any subcontractors you use): 10. Please give names of recent projects and total tons of cargo handled in each case. Please also include cargo types and locations where operations took place: 11. Total Receipts or number of TEU for stevedoring / cargo handling only for last 12 months. 12. Please provide specimen stevedoring / cargo handling contract wording on which you contract with your Clients / Principals Page 3
13. What (if any) activities are subcontracted? Please identify your subcontractors. (Please attach specimen agreement on which you subcontract with subcontractors). 14. Do you also provide inland transit from / to piers or port warehouses to your Clients / Principals? 15. Please indicate what vehicles are used, the typical number of transits in any one year and the typical inland destinations to which cargo is moved overland: 16. What other services may be provided by your Company to your Clients / Principals? (eg: customs clearance, forwarding, packing / unpacking, ships supplies, etc.) 17. Details of claims (by principals or any insurers or any third parties) made against your Companywhether insured or not - paid or not - in the last 5 years arising out of your stevedoring / cargo handling operations: (exclude incidents where amounts claimed are less than ThB 50,000): Page 4
18. Please state who your current insurers are: 19 Please also give us any other information that would be relevant to underwriters in assessing the risk of insuring your Company s operations, (eg details of any staff assigned to safety / risk management, staff training programs, industry awards, ISO 9000 accreditation, etc.): Please attach any Company profile / brochures, web page addresses, etc. if available, for your Company. DECLARATION: The foregoing information is confirmed as being true and correct, and may be used by QBE to assess the risk of insuring our Company s operations. Any terms provided by QBE may be subject to survey(s) of the Company s operations / vessels / equipment / vehicles by QBE appointed surveyors at the expense of our Company. Signed: Name: Date: (Authorised Signatory for the Company) Page 5