Marine Contractor Liability

COMPANY  NAME __________________________________________________ 

ADDRESS   ______________________________________________________________________

CITY          ______________________________________________________________________

E-MAIL     ______________________________________________________________________

PHONE NUMBER  ______________________________________________________________________    

MARINE  GENERAL LIABILITY (   ) $2,000,000  (   )  $1,000,000    (    )  $500,000      (   ) $300,000

DOES THE COMPANY OWN A MARINA?_______. TOTAL SALES $ ____________________

INDICATE   MARINE ARTISAN TRADES            OR                            SMALL MARINE CONTACTOR TRADES

(   ) MARINE VALVE WORK      (    ) MARINE WELDING   (   ) BEACH RESTORATION  

(   ) MARINE  CARPENTRY        (    ) OUTFITTING              (   ) BOAT & TRAVEL LIFT INSTALLATION REPAIR     

(   ) MARINE ELECTRONICS      (    ) PROP REPAIR            (   ) DOCK & GANGWAY CONSTRUCTION & REPAIR 

(   ) MARINE ENGINE REPAIR  (    ) SAIL CANVASS REP   (   ) DREDGING         

(   ) MARINE REFRIGERATION & PLUMBING                    (   ) MARINE OUTFLOW TUNNEL               \

(   ) MARINE RIGGING WORK  (    ) SHRINK WRAPPING (   ) MARINE PILE DRIVING /COFFERDAMS     

(   ) MARINE WELDING             (    ) SODA BLASTING       (   ) SEAWALL/BREAKWATER CONSTRUCTION-REP

 (  ) VESSEL COMMISSIONING (    ) VESSEL PAINTING     (   ) VESSEL SALVAGE                           

(   ) WINTERIZATION.                                                            (   ) WHARF CONSTRUCTION

PROPERTY      (    ) BUILDING LIMIT  $_____________   (    ) CONTENTS  $____________  (     ) TOOLS $____________ OTHER ___________________

BUSINESS AUTO  (   ) $2,000,000    (    ) $1,000,000.  (   ) $500,000.  (    ) $ 300,000 

Year     Make   Model   VIN (17 DIGITS)                                           COMPREHENSIVE  COLLISION DEDUCTIBLE

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NAME                                  DATE OF BIRTH                   DRIVERS LICENSE                        STATE

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WORKERS COMPENSATION     CLASS/TYPE OF WORK _____________  REMUNERATION________________________FED TAX ID     ______________________            

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