PORTS & TERMINALS QUESTIONNAIRE
1. GENERAL INFORMATION
1. Name of Insured
2. Main Address
Postcode:
Main Telephone No.
Email Address Website Address
3. Other addresses/ locations
Postcode:
Year Established No. of Employees Full Time
Part Time
Directors/Officers/Partners
4. Are you a member of any Trade Associations? Yes No
If YES, which ones?
PORTS & TERMINALS QUESTIONNAIRE
2. INFORMATION ON YOUR INFRASTRUCTURE
1. Are you a
Landlord Port? Yes No If YES what % income is derived? %
Operational Port? Yes No If YES what % income is derived? %
If you are a Landlord Port please state your top three tenants
1
2
3
2. Please describe your current activities
3. Please indicate which of the following you operate from your Port / Terminal
i) Berths
Number
Total Length
Maximum Draft Accommodated
How often surveyed above and below water line
ii) Warehouses
Number Dry
Number Reefer
Walls
Roof
Sprinklered
Area m2
Construction type: Maximum Value Stored
Average Value Stored
Fire Detection
Fire Prevention
CCTV
24hr Occupation/Security
PORTS & TERMINALS QUESTIONNAIRE
Inland Clearance Depot/Container Freight Station
Number
Area m2
Perimeter Fenced
Manned Entry/Exit
CCTV
24hr Occupation/Security
iii) Container Repair Facility
Number
Stand Alone Area
Any Non Marine Work?
Hot Work Procedures
iv) Offices/Administration Buildings
Walls
Roof
Sprinklered
Fire Detection
Fire Prevention
24hr Occupation/Security
v) Other: Please provide details
PORTS & TERMINALS QUESTIONNAIRE
3. INFORMATION ON YOUR ACTIVITIES/SERVICES
1. Do you employee Standard and/or National Trading Conditions? Yes No If YES, please supply copies
2. Do you employee your own Trading Conditions? Yes No If YES, please supply copies
3. On which basis do your contracts operate? No Contracts Limited Liability Unlimited
4. Please indicate which of the following services you provide
Provided Sub Sub Contractors Policies Checked
Directly Contracted Limit of Annually
Insurance
Marine Terminal Operator
Stevedore
Freight Forwarder/NVOCC
Warehousing/Storage
Road Transport Operator
Marina
Pilotage
Dredging
Salvage/Removal of Wreck
Navigational Control
Buoys and Navigational Aids
Tugs
Bunkering
Security
Fire/Emergency Services
Repair and Maintenance
Diving
Waste Disposal
Concessions, Hotels, Bars, Shops, etc
Others
5. Who are your major customers? (note all information will be treated in the strictest confidence)
PORTS & TERMINALS QUESTIONNAIRE
6. Other Activities
Do you perform any of the following activities/services?
i) Mixing or blending of fuels, oils, chemicals either for Third Party clients or bunkering purposes?
Yes No
ii) Any non marine repair work e.g. for external engineering firms?
Yes No
iii) Waste disposal of any waste other than vessel’s domestic waste
e.g. any chemicals/high hazard waste?
Yes No
7. Management Features
i) Do you have a Disaster Recovery Plan in respect of fire, pollution, any other catastrophic event?
Please supply a copy if available.
Yes No
ii) A system of regular maintenance and checks on all plant machinery and equipment?
Yes No
iii) Continual documentation checks throughout the terminal?
Yes No
iv) Please separately describe the actions undertaken in order to comply with the ISPS Code.
v) Please separately provide any surveys of your location that have been carried out within the last 3 years.
8. Your Subcontractors/Service Providers
Do you require Sub Contractors and other service providers to indemnify you against their own negligence?
Yes No
Do you insist on being named as an Additional Assured on their policies?
Yes No
Do you provide any indemnities/hold harmless towards other parties?
Yes No
Do you waive any liability towards any other parties?
Yes No
PORTS & TERMINALS QUESTIONNAIRE
4. INFORMATION ON YOUR THROUGHPUT/INCOME
1. Please provide your annual volumes for the following:
Type of Cargo Last Year This Year Next Year
Containers TEU
Containers Reefer
Containers Extrasize
Breakbulk Tonnes
Dry Bulk Tonnes
Wet Bulk Tonnes
Non Hazardous Liquid Bulk
Cars (Private / Commercial)
Passengers
Livestock
Project Cargo/High Value
Heavy Lift
Gross Revenues USD Last Year This Year Next Year
Cargo Handling
Storage
Repair
Other
Totals
0-5,000 GT 5-10,000 GT 10-15,000 GT 15,000 GT+
Vessel Calls
PORTS & TERMINALS QUESTIONNAIRE
5. PROPERTY, EQUIPMENT AND BUSINESS INTERRUPTION
IF COVER IS REQUIRED PLEASE REFER TO SEPARATE PROPOSAL FORM
6. INFORMATION ON YOUR INSURANCE HISTORY
1. For the last three years please indicate your broker and insurance company
Current Broker
Broker, last year
Broker, 2 years previous
Current Insurer
Insurer, last year
Insurer, 2 years previous
2. Has any insurer:
i) Ever cancelled your insurance? Yes No
ii) Refused to renew any aspect of your insurances? Yes No
iii) Declined to insure any aspect of your insurances? Yes No
3. If you have answered YES to any of the above please provide us with some details
PORTS & TERMINALS QUESTIONNAIRE
7. YOUR CLAIMS HISTORY
1. Please provide your claims records for the last 5 years. Figures entered should be from the ground up, i.e. without
application of your excess/deductible at the time
Paid USD Outstanding USD Total USD
Year
Current
Less one
Less two
Less three
Less four
2. Please detail any claim over USD 100,000
D.O.L. Details of Claim Paid USD O/S USD Fees USD Total USD
8. YOUR INSURANCE REQUIREMENTS
1. Please indicate the limits you require for the following sections of cover
Section 1 – Liability to Cargo USD
Section 2 – Third Party Liability USD
Section 3 – Professional Indemnity USD
Section 4 – Liability to Authority USD
Section 5 – Handling Equipment USD
Section 6 - Property USD
Section 7 – Business Interruption/Port Blockage USD
2. Please indicate the excess/deductible you require USD
3. If Business Interruption arising out of Port/Berth Blockage is required
a) Could you supply a plan of your Port/Terminal?
b) Advise back up facilities you have in the event of an emergency?
PORTS & TERMINALS QUESTIONNAIRE
9. ANY OTHER INFORMATION
Please detail any further information that may be material to the risk. Please feel free to attach any additional
sheets and information.
PORTS & TERMINALS QUESTIONNAIRE
ANY OTHER INFORMATION
Continued
PORTS & TERMINALS QUESTIONNAIRE
10. DECLARATION
We declare that the information and answers given in this form are true to the best of our knowledge and belief and that
we have not mis-stated or suppressed any material facts that might influence Underwriters’ assessment of the risk. We
also understand that completion of this form does not bind either the Underwriter or yourselves to accept this
insurance, but if terms are agreed, it will form part of our contract with you.
Signed
Position
Date
DATA PROTECTION ACT
We will collect certain information about individuals within or connected to your company and any subsidiaries (“data
subjects”) in the course of considering your application and, if we issue a policy, in conducting our relationship with you.
This information will be processed for the purpose of underwriting your insurance coverage, managing any policy issued,
providing risk management advice and administering claims. We may pass the information to our reinsurers, legal
advisers, loss adjusters or agents for these and other purposes. This may involve its transfer to countries which do not
have data protection laws.
Some of the information we collect may be classified as ‘sensitive’ – that is, information about disciplinary proceedings,
convictions, sentences or alleged criminal activities. Data protection laws impose specific conditions in relation to
sensitive information including, in some circumstances, the need to obtain the explicit consent of data subjects before
we process the information. Data subjects have a right of access to, and correction of, information that we hold about
them. If they would like to exercise either of these rights, they should contact our Data Protection Compliance Officer at
3rd Floor, 16 St. Clare Street, London EC3n 1LQ, U.K..
By signing this proposal form you confirm the consent of the data subjects to the processing and transfer of information
(including sensitive information) described in this notice, and that you have taken all steps necessary to inform them of
our processing and your disclosure of information to us for the purposes described above. Without this consent and
your confirmation of these matters, we would not be able to consider your application.
