SCHEDULE
This Schedule forms part of and incorporates by reference LMA3021 (the ‘Agreement’),
which Agreement is identified by the Agreement Number and Unique Market Reference
Number stated below. For the purposes of interpretation, the contents of this Schedule
shall have meaning only as provided for in the Agreement.
Agreement Number:
Unique Market Reference
Number:
The Coverholder:
Address:
The Lloyd’s Broker:
Address:
AGREEMENT SECTION
NUMBER
NARRATIVE
Sub-section 2.1
PERIOD:
From: {Inception Date}
To: {Expiry Date}
Both days inclusive, any time zone
Sub-section 3.1
THE PERSON(S) RESPONSIBLE FOR OPERATION AND CONTROL:
Sub-section 3.2
THE PERSON(S) AUTHORISED TO BIND INSURANCES:
Sub-section 3.3
THE PERSON(S) AUTHORISED TO ISSUE DOCUMENTATION EVIDENCING COVER
FOR INSURANCES BOUND:
Sub-section 3.4
THE PERSON(S) AUTHORISED TO EXERCISE ANY CLAIMS AUTHORITY:
Section 6
AUTHORISED CLASS(ES) OF BUSINESS AND COVERAGE(S):
Subject to the terms, conditions, exclusions and limitations of
the Agreement.
Sub-section 7.5
OTHER EXCLUDED CLASSES OF BUSINESS AND COVERAGES:
Subject to the provisions of any country or territory specific
conditions or other conditions or requirements incorporated by
reference and attached hereto.
Sub-section 8.1
PERIOD OF INSURANCES BOUND:
(
) months
MAXIMUM PERIOD OF INSURANCES BOUND:
(
Sub-section 8.3
) months including odd time
NO INSURANCE SHALL BE BOUND FURTHER THAN
(
) days
IN ADVANCE OF ITS INCEPTION DATE.
Section 9
MAXIMUM LIMITS OF LIABILITY OR SUMS INSURED:
Sub-section 10.1
GROSS PREMIUM INCOME LIMIT:
Sub-section 10.2
NOTIFIABLE PERCENTAGE OF THE LIMIT NOT TO EXCEED:
%
TIME SPECIFIED FOR NOTICE IF THE NOTIFIABLE PERCENTAGE IS LIKELY TO BE
EXCEEDED:
(
) days
Sub-section 11.1
INSURANCES MAY ONLY BE BOUND FOR RISKS LOCATED OR INSUREDS
DOMICILED IN:
Sub-section 11.2
MAXIMUM TERRITORIAL LIMITS OF INSURANCES BOUND:
Sub-section 12.1.1
FORMAT FOR DECLARATION BORDEREAUX:
Sub-section 12.1.3
DECLARATION BORDEREAUX INTERVAL:
*Monthly / Quarterly
*(Delete as applicable)
Sub-section 12.2
MAXIMUM PERIOD FOR SUBMISSION OF DECLARATION BORDEREAUX:
( ) days
Sub-section 12.3.1
BASIS OF MONITORING AGGREGATE EXPOSURES:
Sub-section 12.3.2
REPORTING INTERVALS:
*Weekly / Monthly / Quarterly
*(Delete as applicable)
Sub-section 12.3.3
MAXIMUM TOTAL AGGREGATE EXPOSURE LIMIT(S):
Sub-section 13.1
BASIS FOR THE CALCULATION OF GROSS PREMIUMS:
Sub-section 13.2
DEDUCTIBLES AND OR EXCESSES:
Sub-section 14.1
OTHER CONDITIONS AND OR REQUIREMENTS TO THE AGREEMENT:
Sub-section 14.3
AMENDMENTS TO THE AGREEMENT:
Sub-section 15.3
REPORTING INTERVAL FOR AUTOMATIC OR TACIT RENEWALS:
( ) *days / Weekly / Monthly / Quarterly
*(Delete as applicable)
Sub-section 16.1.1
NUMBER OF DAYS’ NOTICE OF CANCELLATION:
( ) days
Section 18
APPLICATION AND PROPOSAL FORMS:
Sub-section 19.8
VARIATIONS TO THE STATED PROCEDURE IN RELATION TO COPY DOCUMENTS:
Section 20
FORMAT OF DOCUMENTATION EVIDENCING COVER ISSUED
COVERHOLDER FOR AND ON BEHALF OF THE UNDERWRITERS:
Sub-section 21.1
WORDINGS, CONDITIONS, CLAUSES, ENDORSEMENTS, WARRANTIES AND
EXCLUSIONS APPLICABLE TO INSURANCES BOUND:
BY
THE
For cargo war risk insurances the current relevant London
Institute War Clauses (Cargo) or the Standard War Risk Clauses
of any country which complies with the limitations of the
United Kingdom Waterborne Agreement.
If this Agreement provides for reinsurances for cargo war risk
reinsurances the current Paramount War Clause (Cargo).
Sub-section 21.4.2
THE ADDRESS OF THE FSA IS:
Sub-section 21.5
SEVERAL LIABILITY:
Sub-section 21.6
THE LAW AND JURISDICTION APPLICABLE TO INSURANCES BOUND:
Sub-section 21.7
HULL WAR AND STRIKES CANCELLATION CLAUSE:
For hulls, shipowners, other interests, charterer’s interests
(other than cargo), builders risks and second seamans
insurances for time or voyage the current London Institute
Notice of Cancellation and War Automatic Termination of
Cover Clause or corresponding clauses approved by the London
Joint War Committee.
CARGO WAR AND STRIKES CANCELLATION CLAUSE:
In respect of Marine, Air Cargo and Postal Insurance which
cover the risks of War, Strikes, Riots and Civil Commotions,
the following provisions shall apply to the Agreement and to
any Open Cover granted by the Coverholder:
War risks may be cancelled at seven days’ notice.
Strikes, Riots and Civil Commotions risks may be cancelled at
seven days’ notice or forty-eight hours’ notice in respect of
shipments and or sendings to or from the U.S.A.
Notice shall commence from midnight of the day when it is
issued but cancellation shall not apply to any risks which have
attached in accordance with cover granted hereunder before
this cancellation becomes effective.
Sub-section 22.2
COMBINED CERTIFICATES:
other Lloyd’s Underwriters - *Permitted / Not permitted
non-Underwriting Members of Lloyd's - *Permitted / Not
permitted
(Subject always to the provisions of Section 22)
*(Delete as applicable)
Sub-section 22.2.1
IDENTITY OF OTHER INSURERS:
Sub-section 24.1.1
PER CLAIM LIMIT OF AUTHORITY:
Sub-section 24.1.3
ANY CLAIM EXCEEDING OR LIKELY TO EXCEED THE AUTHORITY LIMIT SHALL BE
NOTIFIED TO THE UNDERWRITERS WITHIN THE FOLLOWING PERIOD AFTER THE
COVERHOLDER IS NOTIFIED OF THE CLAIM:
( ) * hours / days
*(Delete as applicable)
Sub-section 24.1.5
TIME LIMIT FOR NOTIFYING THE UNDERWRITERS OF A CLAIM OR A RECOVERY
LIKELY TO GIVE RISE TO A COMPLAINT:
( ) *hours / days
*(Delete as applicable)
Sub-section 24.1.6
THE UNDERWRITERS AUTHORISE THE COVERHOLDER TO INSTRUCT ADJUSTERS,
SURVEYORS, LAWYERS OR ANY OTHER THIRD PARTIES:
*Yes / No
*(Delete as applicable)
If yes, such parties shall be where appropriate:
Sub-section 24.1.7
THE UNDERWRITERS SHALL BE INFORMED BY THE COVERHOLDER OF THE
APPOINTMENT OF ANY LLOYD’S AGENT WITHIN:
( ) *hours / days
*(Delete as applicable)
Sub-section 25.2
FORMAT FOR PAID PREMIUM BORDEREAUX:
FORMAT FOR CLAIMS BORDEREAUX:
Sub-section 25.3
PAID PREMIUM BORDEREAUX INTERVAL
*Monthly / Quarterly
*(Delete as applicable)
Sub-section 25.4
CLAIMS BORDEREAUX TO BE PRODUCED BY THE COVERHOLDER:
*Yes / No
*(Delete as applicable)
CLAIMS BORDEREAUX INTERVAL:
*Monthly / Quarterly
*(Delete as applicable)
Sub-section 25.6
MAXIMUM PERIOD FOR SUBMISSION OF BORDEREAUX:
( ) days
Sub-section 25.7
MAXIMUM PERIOD FOR REMITTANCE OF SETTLEMENTS WITHIN
(
) days
OF THE END OF THE BORDEREAUX INTERVAL.
Sub-section 25.8
FEES OR CHARGES TO BE REIMBURSED BY THE UNDERWRITERS:
Sub-section 26.1
THE COVERHOLDER’S COMMISSION:
Sub-section 26.2
THE TOTAL COMMISSIONS, BROKERAGE OR FEES PAYABLE:
NOT EXCEEDING (
) % OF GROSS PREMIUM INCOME
(exclusive of any brokerage payable to the Lloyd’s Broker)
Sub-section 26.3
BASIS OF CALCULATION OF CONTINGENT OR PROFIT COMMISSION:
Sub-section 34.2
RECORDS, STATISTICAL INFORMATION, INSPECTIONS AND AUDITS:
REPORTING INTERVAL(S):
*Monthly / Quarterly
*(Delete as applicable)
MAXIMUM NUMBER OF DAYS:
(
Sub-section 35.1
) days
THE COVERHOLDER IS AUTHORISED TO REFER TO LLOYD’S IN ACCORDANCE
WITH THE RULES AND GUIDANCE ISSUED BY LLOYD’S.
*Yes / No
*(Delete as applicable)
Sub-section 35.2
THE COVERHOLDER IS AUTHORISED TO REFER TO THE UNDERWRITERS IN
PROMOTIONAL MATERIAL APPROVED BY THE UNDERWRITERS.
*Yes / No
*(Delete as applicable)
THE COVERHOLDER IS AUTHORISED TO USE ANY LOGO, EMBLEM OR SIMILAR
MARK WHICH IDENTIFIES THE UNDERWRITERS.
*Yes / No
*(Delete as applicable)
Section 38
TIME LIMIT FOR NOTIFYING THE UNDERWRITERS OF ANY POTENTIAL
COMPLAINT, REGULATORY PROCEEDINGS OR LITIGATION:
(
) days
Agreement Number:
Unique Market Reference
Number:
SIGNATURE OF THE COVERHOLDER:
In accordance with Section 1 of LMA3021, the Agreement is signed on behalf of the
Coverholder as acceptance of the terms and conditions of the Agreement inclusive of
any attachments identified in the Schedule.
___________________________________________________________________________
Signed and accepted on behalf of the Coverholder
___________________________________________________________________________
Name and Position of Signatory
___________________________________________________________________________
Date of Signature
ACKNOWLEDGEMENT OF THE UNDERWRITERS:
___________________________________________________________________________
Signed and accepted on behalf of the Underwriters
___________________________________________________________________________
Date of Acknowledgement
LMA 3021(Broker)
26 April 2010
NON-SCHEDULE AGREEMENTS
TAX(ES) PAYABLE BY
INSURED AND
ADMINISTERED BY
INSURERS:
RECORDING,
TRANSMITTING AND
STORING
INFORMATION:
INFORMATION
SECURITY DETAILS
ORDER HEREON:
BASIS OF WRITTEN
LINES:
BASIS OF SIGNED
LINES:
SIGNING PROVISIONS:
N.B. The written lines for the Binding Authority agreement should appear here.
The Several Liability clause to be used for each certificate should be specified within section 21.4
SUBSCRIPTION AGREEMENT
SLIP LEADER:
BUREAU LEADER:
SETTLEMENT TERMS:
BASIS OF AGREEMENT
TO BINDING
AUTHORITY
CHANGES:
BINDING AUTHORITY
ADMINISTRATION:
BINDING AUTHORITY
AGREEMENT
PRODUCTION:
BASIS OF CLAIMS
AGREEMENT:
CLAIMS AGREEMENT
PARTIES:
RULES AND EXTENT
OF ANY OTHER
DELEGATED CLAIMS
AUTHORITY:
EXPERT(S) FEE
COLLECTION:
BUREAU
ARRANGEMENTS:
SPECIAL
ARRANGEMENTS:
FISCAL AND REGULATORY
TAX PAYABLE BY
INSURER(S):
US CLASSIFICATION:
NAIC CODES:
BINDING AUTHORITY
REGISTRATION DATE
AND NUMBER:
ALLOCATION OF
PREMIUM TO
CODING:
REGULATORY
CLIENT
CLASSIFICATION:
IS THE BUSINESS
SUBJECT TO
DISTANCE
MARKETING
DIRECTIVE?:
BROKER REMUNERATION AND DEDUCTIONS
TOTAL BROKERAGE:
OTHER DEDUCTIONS
FROM PREMIUM: