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United PandI
Form


APPLICATION FOR P&I COVER – PART ONE
(Complete all applicable questions)

Principal Insured *

Main Contact:

Second Contact:

* Organisation having commercial control of the ships to be entered.
Co Insured to be named in the certificate of entry **

Co Insured is jointly liable for the payment of premium to the QITA.
Please confirm that this Co Insured has been made aware of their responsibility and has consented to being named by ticking the box and signing below.

Signed: --------------------------------------------------

Co Insured is jointly liable for the payment of premium to the QITA.
Please confirm that this Co Insured has been made aware of their responsibility and has consented to being named by ticking the box and signing below.

Signed: --------------------------------------------------

Co Insured is jointly liable for the payment of premium to the QITA.
Please confirm that this Co Insured has been made aware of their responsibility and has consented to being named by ticking the box and signing below.

Signed: --------------------------------------------------

Insurance History

Company History / Structure

Please provide a brief history of the company and / or its principal shareholders / owner. Please provide details of the company’s operating experience and loss record with previous marine liability / P&I insurers for the last 5 years. Please provide details of the company hierarchy and structure.

Declaration :