3850 N. CAUSEWAY BLVD.
TWO LAKEWAY, SUITE 1160
METAIRIE, LA 70002
520 POST OAK BLVD., SUITE 250
HOUSTON, TX 77027
P.O. BOX 22003
HOUSTON, TX 77227-2003
Charterer’s Legal Liability Application (Aug 2013)
Applicant’s Agent/Broker
Name and address of applicant’s agent/broker:
Is agent/broker licensed in applicant’s Home State?
Is agent/broker a surplus lines broker?
If so, in which state(s)?
YES
YES
or
or
NO
NO
Is this a new account to the agent/broker?
If no, how many years held?
YES
or
NO
Applicant
Applicant’s Name and Address:
Name of principal(s) and owner(s):
Applicant is
Individual
Partnership
Corporation___ LLC
Period of time applicant has been trading.
Effective date of coverage:______________________________________
Charterer’s Legal Liability Application
Page 1 of 4
Has Applicant ever had a
cancelled?
If yes, please provide details:
Charterer’s
placement
YES
or
NO
Has Applicant ever had insurance declined for this class
of business?
If yes, please describe details:
YES
or
NO
Operations
Describe Nature of Applicant’s Operations:
Time Chartered
Vessels
Voyage
Chartered
Vessels
Bareboat
Chartered
Vessels
Number Chartered
Duration of Charters
Cargo included, if
so advise type of
cargo.
Types of Vessels Chartered
Type of Vessel
GRT
Charterer’s Legal Liability Application
Class
Age
Owner
Page 2 of 4
Intended
Charter:
cargo
during
period
of
If any of the chartered vessels are
not
specifically
designated
for
charterer’s intended cargo, please
explain:
Approximate value per shipment of
intended cargo:
Owner of cargo:
Who is responsible for loading?
Who is responsible for stowing?
Who is responsible for discharging?
Intended Ports of Loading:
Intended Ports of Discharging:
Who issues the bills of lading?
What bill of lading conditions apply? (attach samples)
Charterer’s Legal Liability Application
Page 3 of 4
Losses
Attach 5 year loss run that shows each claim individually and include
 Assured’s deductible
 Amount paid and reserve, if any
 Description of claim
General
Limit of liability being requested
____________________
Deductible being requested
________________________
THE APPLICANT WARRANTS THAT THE INFORMATION PROVIDED ABOVE IS COMPLETE
AND ACCURATE. APPLICANT UNDERSTANDS THAT UNDERWRITERS SHALL RELY UPON
THE INFORMATION AND REPRESENTATIONS PROVIDED ABOVE IN DETERMINING THE
ACCEPTABILITY, RATES AND CONDITIONS OF COVERAGE.
IT IS UNDERSTOOD THAT ANY MISREPRESENTATION OR OMISSION SHALL CONSTITUTE
GROUNDS FOR IMMEDIATE AVOIDANCE OF OR CANCELLATION OF COVERAGE AND DENIAL
OF CLAIMS, IF ANY.
IT IS FURTHER NOTED AND UNDERSTOOD THAT THE APPLICANT IS UNDER A CONTINUING
OBLIGATION TO IMMEDIATELY NOTIFY UNDERWRITERS OF ANY MATERIAL ALTERATION
AS TO THE NATURE, EXTENT OR SIZE OF ITS OPERATION AS DESCRIBED HEREIN.
THE INFORMATION CONTAINED HEREIN IS FOR THE PURPOSE OF OBTAINING A
PROPOSAL OR QUOTATION FOR INSURANCE FROM ANY ONE OF SEVERAL INSURANCE
COMPANIES OR UNDERWRITERS AND CREATES NO OBLIGATION ON THE PART OF BLADES
MARINE, A DIVISION OF J.H. BLADES & CO., INC. OR ANY INSURANCE COMPANY OR
UNDERWRITER.
_______________________________
Authorized Representative of Applicant
_______________________________
Title
_______________________________
Date
Charterer’s Legal Liability Application
_____________________________
Applicant’s Agent/Broker
_____________________________
Date
Page 4 of 4