QBE MARINE P&I Cover MARINE PROTECTION & INDEMNITY INSURANCE

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1 QBE MARINE P&I Cover MARINE PROTECTION & INDEMNITY INSURANCE Primary Proposal You need a specialist insurance solution to help propel your business through the complex hazard of marine liability risks.

2 QBE MARINE P&I Cover TM MARINE PROTECTION & INDEMNITY INSURANCE PRIMARY PROPOSAL Contents A. NOTICE TO THE PROPOSED INSURED B. REGULATORY STATEMENTS C. DETAILS OF APPLICANT D. DETAILS OF YOUR MARKET E. COVERAGE / CERTIFICATION REQUIREMENTS F. VESSEL PARTICULARS G. LOSS INFORMATION H. ADDITIONAL INFORMATION I. WARRANTY A. NOTICE TO PROPOSED INSURED 1. Disclosure of Relevant Facts Your Duty of Disclosure Before you enter into a contract of general insurance with an insurer, you have a duty to disclose to the insurer every matter which you know, or could reasonably be expected to know, is relevant to the insurer's decision whether to accept the risk of the insurance and, if so, on what terms. You have the same duty to disclose those matters to us before you renew, extend, vary or reinstate a contract of insurance. Comment The requirement of full and frank disclosure of anything which may be material to the risk for which you seek cover (eg. claims, whether founded or unfounded), or to the magnitude of the risk, is of the utmost importance with this type of insurance. It is better to err on the side of caution by disclosing anything which might conceivably influence the insurer's consideration of your proposal. 1

3 B. REGULATORY STATEMENTS In addition to the Notice to the Proposed Insured (see Section A.) please refer to the table below for the regulatory statement that is relevant to the jurisdiction from which you will be making your application. Hong Kong Indonesia Macau Malaysia Philippines Singapore Thailand Vietnam Other Markets Fiji French Polynesia New Caledonia Papua New Guinea Solomon Islands Vanuatu Other Markets Asia Markets QBE Hongkong & Shanghai Insurance Limited PT Asuransi QBE Pool Indonesia QBE Insurance (Malaysia) Berhad WARNING: Statement pursuant to Section 149(4) of the Insurance Act 1996 (Act 553) You are to disclose in this proposal form, fully and faithfully, all the facts which you know, otherwise, the policy issued hereunder may be void. Please also refer to the Notice to the Proposed Insured in Section A QBE Insurance (Philippines) Inc. Pursuant to Section 25(5) of the Insurance Act (Chapter Revised Edition as at 1 July 2000) and any subsequent amendments, modifications or re-enactment thereof that insured are to fully and faithfully disclose in the proposal form all the facts and matters which they know or ought to know, otherwise the Policy issued hereunder may be void. Please also refer to the 'Notice to the Proposed Insured' in Section A QBE Insurance (Thailand) Company Limited Warning of Insurance Department Under the Civil & Commercial Code section 865, Insured must answer all questions truthfully. Any non-disclosure or misrepresentation may cause the company to deny claims under the policy. Please also refer to the Notice to the Proposed Insured in Section A BIDV-QBE Insurance Company Limited Do not use this proposal form. Please contact your local QBE office for the proposal form relevant to the jurisdiction of your market. Pacific Markets QBE Insurance (Fiji) Limited QBE Insurance (PNG) Limited QBE Insurance (Vanuatu) Limited Do not use this proposal form. Please contact your local QBE office for the proposal form relevant to the jurisdiction of your market. The content and use of this form and any agreement entered into pursuant to this form or any dealing in relation to or arising from this form is governed by the laws of the country in which this form is submitted and in relation to those matters, the parties submit to the jurisdiction of the courts of that country. 2

4 IMPORTANT Please answer ALL questions fully. If there is insufficient space please provide details on your letterhead. Where provided, tick ( ) appropriate box to indicate answer. The Applicant will be referred to in this Proposal as You or Your. C. DETAILS OF APPLICANT 1. Full name of all entities to be insured (including service, administrative or nominee companies and subsidiaries that you wish to be covered by this policy): (Hereinafter the applicant will be referred to as You or Your ) 2. Your Principal Address: 3. (i) Telephone (ii) (iii) (iv) Telephone Telex 5. What is the Applicant s status? Shipowner Manager Bareboat Charterer Other 6. Has the Applicant and/or any affiliated companies owned or operated any vessels other than those in respect of which this application is made? Yes No 7. Has the Applicant and/or any affiliated companies traded under any other names within the last 5 years? Yes No 8. Has Applicant and/or any affiliated companies been denied coverage or been subject to cancellation by P&I, Hull or other Underwriters? Yes No 3 FC/QBE961E/

5 9. Does the Applicant hold a valid Document of Compliance (DOC) in compliance with the International Safety Management (ISM) Code? Yes No D. DETAILS OF YOUR MARKET Please complete the following section by indicating: 1. Which market you want the policy to be written in (the QBE Insurer for each market is indicated below for your reference); and 2. The currency for the policy QBE Asia Pacific operations Asia Market Business Name Please tick ( ) Market Currency Hong Kong QBE Hongkong & Shanghai Insurance Ltd HKD Indonesia PT Asuransi QBE Pool Indonesia IDR Macau MOP Mainland China QBE Insurance Group Limited Guangzhou Representative Office CNY Malaysia QBE Insurance (Malaysia) Berhad MYR Philippines QBE Insurance (Philippines) Inc PHP Singapore SGD Thailand QBE Insurance (Thailand) Company Limited THB Vietnam BIDV-QBE Insurance Company Limited VND QBE Asia Pacific operations Pacific Market Currency Fiji QBE Insurance (Fiji) Limited FJD French Polynesia XPF New Caledonia XPF New Zealand NZD Papua New Guinea QBE Insurance (PNG) Limited PGK Solomon Islands SBD Vanuatu QBE Insurance (Vanuatu) Limited VUV E. COVERAGE / CERTIFICATION REQUIREMENTS (i) Cargo (subject to approval Bills of Lading) Yes No (ii) R.D.C. ( /4ths required) Yes No (iii) Defence (Legal Costs & Expenses) Yes No (iv) COFR required Yes No (v) Crew (subject to approval of crew contract) Yes No (vi) Pollution Yes No (vii) Limit of Liability required US$ million (maximum US$ 100 million) (viii) Coverage required from / / 4

6 F. VESSEL PARTICULARS Vessel Description (i) (ii) (iii) (iv) (v) Vessel Name Ex Name Year Acquired Vessel Type Gross Tonnage (vi) 1969 Tonnage Convention? Yes No (vii) (viii) (ix) Year Built Current P&I Insurer Is the vessel specifically designed or modified with the approval of class for the carriage of cargo on deck? Yes No Classification / Certification (i) (ii) (iii) (iv) (v) (vi) Class Date of Registration with Class Society Previous Class Next Special Survey Due Have all outstanding recommendations of the current or previous classification society been complied with? Yes No Is the vessel in possession of a valid Safety Management Certificate (SMC) in compliance with the International Safety Management (ISM) code? Yes No Trading Area for the last & next 12 months Australasia Papua New Guinea Eastern Russia Pacific Island** East Coast Africa Europe Far East Mediterranean Middle East North America Intended Cargoes for the last & next 12 months Bulk Ore / Coal Bulk Perishable Containerised Gas General Cargo Heavy Lift / Project Liquid Livestock Logs Passengers 5

7 Scandinavia South America West Coast Africa Other (specify) Refrigerated Ro-Ro Steel Other (specify) Other (specify) **Pacific Islands Include :Soloman Islands, Vanuata, Fiji, Tonga, Cook Islands French, Polynesia, Pitcairn Islands Condition Survey (i) Has the vessel been subject to a P&I condition survey within the last 2 years? Yes No (ii) Were any recommendations made in the P&I condition survey? Yes No If so, have they been rectified? Yes No (iii) Please state the next 3 ports at which the vessel will be available for inspection if required Crew Numbers Nationality Applicable State Compensation Scheme Officers Ratings Others 6

8 G. LOSS INFORMATION Complete this schedule for all vessels owned or operated during the last 5 years or attach a recently produced loss record print-out from P & I insurers. Please list all reported incidents for all classes of insurance in respect of which this application is being made during the last five years. The list must include all previously closed claims, including those closed without payment, all incidents whether an estimate of loss has been set or not and all other claims where an estimate has been set and / or payment made. Vessel Name Date of Loss Details of Loss Amount Paid Amount Outstanding Please state when the above figures were last reviewed / / 7

9 H. ADDITIONAL INFORMATION Please use this section to provide additional or supplementary information I. WARRANTY The Applicant warrants that the information provided above is complete and accurate to the best of his knowledge and belief. It is understood that Underwriters shall rely upon the information and representations listed herein in determining the acceptability, rates and conditions of coverage. Any misrepresentation or omission shall constitute grounds for immediate cancellation of coverage and denial of claims, if any. It is further noted and understood that the Applicant is under a continuing obligation to immediately notify Underwriters of any material alteration to the nature, extent or size of his operation as described herein. This application shall be attached to and form part of the Policy of Insurance. Signed: Date / / Title: Your Insurance Adviser or Broker 8

10 Licensed insurers providing QBE Marine Risks Network products: Asia Markets Hong Kong QBE Hongkong & Shanghai Insurance Co. Limited 6/F DCH Commercial Centre 25 Westlands Road, Quarry Bay Hong Kong Tel: Indonesia PT Asuransi QBE Pool Indonesia MidPlaza 2, 23rd floor Jalan Jenderal Sudirman Kav Jakarta Tel: +62 (21) Macau No , Avenida Da Praia Grande 9º andar B, Edificio Keng Ou Tel: Malaysia QBE Insurance (Malaysia) Berhad No. 638 Level 6, Block B1 Pusat Dagang Setia Jaya (Leisure Commerce Square) No. 9 Jalan PJS 8/ Petaling Jaya Selangor Darul Ehsan, Malaysia Tel: +60 (3) Philippines QBE Insurance (Philippines) Inc. 16th floor, Equitable Bank Tower Building 8751 Paseo de Roxas Makati City 1226 Tel: +63 (2) Singapore QBE Marine Underwriting Agency Pte Ltd 65 Chulia Street #18-01 OCBC Centre (West Lobby) Singapore Tel: Thailand QBE Insurance (Thailand) Company Limited 161/1, 11th 12th floor, SG Tower Building Soi Mahatlekluang 3 Rajdamri Road Lumpinee, Pathumwan Bangkok Tel: +66 (2) Vietnam BIDV-QBE Insurance Company Limited 7th floor, North Star Building 4 Da Tuong Street Hoan Kiem District Hanoi Tel: +84 (4) Pacific Islands Markets Fiji QBE Insurance (Fiji) Limited QBE Centre Victoria Parade GPO Box 101 Suva Tel: Papua New Guinea QBE Insurance (PNG) Limited QBE Building Musgrave Street PO Box 814 Port Moresby Tel: Vanuatu QBE Insurance (Vanuatu) Limited La Casa D Andrea Building Port Villa PO Box 186 Tel: +678 (2) 2299 Solomon Islands ABN st floor, Centrepoint Building Mendana Avenue PO Box 764 Honiara Tel: French Polynesia ABN Immeuble Galliéni Front de Mer PO Box 283 Papeete, Tahiti Tel: New Caledonia ABN Rue Anatole France, BP Noumea-Cedex Noumea Tel: New Zealand Market New Zealand Level 6, Quay Tower 29 Customs Street West Auckland Tel: +64 (9) For literature in use in the other markets, please contact the local office. QBE INSURANCE (INTERNATIONAL) LIMITED (ABN ) A member of the worldwide QBE Insurance Group Head Office: Level 7, 345 George Street, Sydney NSW 2000, Australia GPO Box 82, Sydney NSW 2001, Australia Tel: Fax To find out more about the QBE Specialist Risks Unit go to