Gregory Marine Insurance

Ship Repair Insurance

All Fields Marked(*) are Required

Personal Information

Home Phone:
Work Phone:
Cell Phone:
At least one phone number is required (*)
E-Mail:*

Work Performed

Types of Work Performed (Please select all that apply) *

Canvas Repair:

Gas Freeing:

Canvas Installation:

Painting:

Carpentry:

Rigging:

Cleaning / Detailing:

Welding:

Electrical Repair/Installation:

Private Pleasure Craft:

Fiberglass:

Engines:

Details:

Commercial
Watercraft:

Details:

Other:

Specify:

General Information


1. Does your work include diving? *	Yes No
If so, please describe underwater activities and percentage of overall work this represents




2. Are propellers pulled and/or replaced? *	Yes No



3. Maximum Value any one vessel: *	$
4. Maximum Value any one time: *	$



5. Do you tow any watercraft? *	Yes No
6. Do you haul/launch? *	Yes No



7. Do you operate any watercraft as part of your work? *	Yes No
If yes, please describe:




8. Do you have the watercraft or any of its equipment in or on any property you own, rent or lease? *	Yes No
If yes, please describe:




9. Do you have docks or slips at your place of business? *	Yes No
If yes, how many?




10. Do any of your customers visit your place of business? *	Yes No
If yes, explain:




11. Are you a sub-contractor? *	Yes No
12. Do you sub-contract? *	Yes No
If yes, explain:




13. How many years have you performed this work? *
14. Gross receipts, including parts and labor: *	$
15. How many people do you employ? *



16. Do you perform any other work or service or provide or sell any other parts, equipment or material in your business? *	Yes No
If yes, explain:

17. What are the receipts or sales for this other operation?	$

Losses

Describe all losses, whether insured or not, for the last 5 years. (State None if None)

	Description of Loss	Amount Paid
1		$
2		$
3		$
4		$
5		$

Insurance / Liability Information


1. Current Insurance Company:*



2. Has your insurance ever been cancelled?*	Yes No
If yes, explain:




3. Limit of Liability: *	$
4. P&I Insurance? *	Yes No



Date policy to be effective: *

Tools and Equipment


Where are goods stored when not is use?




What measures are used to reduce theft and/or vandalism damage to the equipment?

Describe all tools or equipment losses, within the last 5 years. (State None if None)

	Date of Loss	Amount Paid	Deductible	Cause of Loss
1
2
3
4
5


Schedule of property to be covered

	Item Number	Description-Manufacturer-Model	Amount of Insurance
1
2
3
4
5