1. Name of Applicant
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First Name
Last Name
2. Address
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PO Box
City
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State
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Zip
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Home Phone
(###)
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Mobile Phone
(###)
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Email Address
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Date you would like your policy to start (MM/DD/YY):
MM
DD
YYYY
3. What is your current sailing grade? (Please provide the grade at which you are working now, even if your license is for a different grade.)
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4. Who is your current employer?
5. Do you serve aboard a tug?
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Do you serve aboard a towing vessel?
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Do you serve aboard a passenger vessel?
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6. Are you involved in the delivery or transportation of private or corporate yachts or in any charter operations? (If yes, certain coverage limitations may apply.)
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7. If you are currently working exclusively as a pilot, please indicate what type:
1. Have you ever been involved in, or are you aware of, any marine incident or incidents that occurred while sailing under your marine license(s) that could have resulted in, or may still result in, action against your license(s) and/or resulted in, federal, state or local criminal charges being brought against you?
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If yes, please explain:
2. Has your marine license(s) ever been defended before the U.S. Coast Guard, National Transportation Safety Board, state pilotage authority(ies) and/or any other authority(ies) during the past five (5) years?
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3. Has your marine license(s) ever been revoked, suspended or reduced in grade?
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4. Have you ever been named in a civil lawsuit resulting from an incident(s) that occurred while sailing under your marine license(s)?
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If yes, please explain:
5. Have you ever been named in a civil penalty action resulting from an incident(s) that occurred while sailing under your marine license(s)?
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If yes, have you ever been ordered to pay a civil penalty fine?
1. Loss of Income
Loss of Income: FULL Monthly Compensation
Income compensation at your full monthly salary - plus daily subsistence payments for up to 12 months if your license is revoked, suspended or reduced in grade resulting from a covered shipping casualty or incident. Please provide your TOTAL MONTHLY COMPENSATION* (base wages, average overtime and vacation pay) (*Total monthly compensation = annual salary divided by 12).
Loss of Income: PARTIAL Monthly Compensation
Income compensation at the amount of salary you choose to insure – plus daily subsistence payments for up to 12 months if your license is revoked, suspended or reduced in grade resulting from a covered shipping casualty or incident. Please indicate the amount of monthly compensation you would like to insure.
2. Civil Legal Defense
Paid legal defense if a civil lawsuit is brought against or served upon you in any court within the United States, its territories or a foreign court resulting from a covered shipping casualty or incident involving your vessel.
All coverage limits subject to underwriter's discretion.
(Please note that if you want Professional/Civil Liability coverage, you MUST request 100K Civil Legal Defense coverage.)
Coverage Limit requested (check one):
3. Professional/Civil Liability (Ask about our reduced rates.)
Professional Liability coverage for additional defense costs and/or judgments in civil court proceedings resulting from a covered shipping casualty or incident.
Quote released at underwriter's discretion. Coverage Limit requested (check one):
4. Civil Penalties Legal Defense
Paid legal defense if you are charged with a civil penalty by the U.S. Coast Guard or any other entity within the United States, its territories, or a foreign court or administrative entity authorized to impose a civil penalty or fine resulting from a covered shipping casualty or incident involving your vessel. Please note that this coverage is DEFENSE only; it does NOT cover payment of the penalty/fine. (Coverage up to $10K.)
5. Criminal Acts Defense
Paid legal defense by experienced criminal attorneys if you are charged criminally in connection with a covered shipping casualty or incident that results in allegations or charges related to federal (OPA-90) and/or state water pollution laws and/or regulations. (Coverage up to $25K.)
How would you like your quote sent to you?
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How did you hear about MOPS?
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If Other, how did you hear about MOPS?
Please provide name of the MOPS policyholder who referred you:
Are you a member of any maritime association?
SELECT
APA
NMA
PVA
CAPCA
NACO
CAMM
MTA
Other
If Other, please list maritime association(s):
Are you a RECENT a graduate of a maritime school or academy?
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If Yes, please provide name of maritime school or academy:
Declaration
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By checking this box, I hereby warrant that the above particulars and statements are true and complete, that I have not omitted or misstated any material fact, and that at the present time I have no reason to anticipate any charges being brought against either me or my United States Coast Guard or state pilotage license(s) for any intentional or unintentional misconduct or negligence. I agree that this application form shall be relied upon and shall be the basis on which any Certificate of Insurance may be issued by the Company and shall be deemed a part thereof. I understand and agree that failure to disclose or misstatement of any information requested in this application may result in the Company denying all coverage in the event of a claim.
