Family ESSENTIAL HEALTH COVER FOR YOUR CREW & THEIR FAMILIES

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1 Sure Family ESSENTIAL HEALTH COVER FOR YOUR CREW & THEIR FAMILIES Effective

2 Sure Family KEY FEATURES Medical Expenses for crew including spouses and dependents in their home country. ABOUT THE COVER The sure Family cover is designed to cover the seafarer for medical expenses whilst on holiday including cover for spouses and dependents in their home country. ABOUT THE INSURERS Family Healthcare is underwritten by Catlin Syndicate Catlin Syndicate 2003 is the largest Syndicate at Lloyd s with 1.43bn of capacity (about 8 per cent of the Lloyd s market) and a recognised leader in all classes. Catlin Syndicate 2003 enjoys A (Excellent) financial strength ratings from A. M. Best Company and an A+ (Strong) financial strength rating from Standard and Poor s. In addition, the syndicate has been assigned a Lloyd s Syndicate Assessment (LSA) of 4 (low dependency) from Standard and Poor s. CLAIMS Claims will be handled by directly by underwriters or by specialists acting on their behalf. They will work with you to provide 24 hour multi-lingual telephone assistance, coordinate and liaise with patients, their families, doctors, nurses and specialists across the world no matter what the time or language. ABOUT CREWSURE sure has created a bespoke all encompassing policy for your seafarers which is designed to meet their needs and the requirements of the modern shipping industry. sure has worked with market practitioners with long experience of the industry. This cover has been created following extensive consultation with many and various maritime interests involved with the employment of seafarers. sure has liaised with Government departments, Unions, Shipowners, Ship Managers, Manning Agents and the Insurance Industry. sure is working with Compass Underwriting, a specialist accident and health underwriting agency who provide administration and IT support. Compass is authorised and regulated by the UK s Financial Conduct Authority and is a Member of the Association of Managing General Agents and the British Insurance Brokers Association.

3 Sure Family COMPLETING THIS PROPOSAL FORM To apply for sure Family cover, complete this in BLOCK CAPITALS using a ball point pen (blue or black ink). Insurance cover does not begin until we have confirmed that your application has been successful and we have written to you with the agreed start date. You must give full and true answers to all questions. If you do not do so, your insurance cover may not protect you in the event of a claim. You should keep a record of all information supplied to sure including copies of any correspondence. A copy of the can be supplied on request. A copy of the Policy is available on request. A GENERAL 1. Full registered name of the business to be insured 2. Business address 3. Date business established 4. Company registration No. 5. Commencement date of cover 6. Renewal date required B CREW TO BE INSURED Please answer the following questions by ticking the appropriate box. If you do not have enough room to complete additional information to answers, please use the space provided in Section G at the end of this application form. 7. Please confirm that all crew have a valid PEME and Certificate of Competence (or its equivalent). YES NO If No, please give details.

4 Sure Family C CREW NUMBERS TO BE INSURED 8. Please complete this question to the best of your knowledge based on actual current data or experience with either actual numbers of insureds or a % estimated breakdown. Filipino Indian EEA/EU Russian/ Ukraine, Eastern Europe & Balkan (non EEA)

5 Sure Family C CREW NUMBERS TO BE INSURED (Cont.) Indonesian, Sri Lanken, Bangladeshi Others* *Note If others represent more than 5% of your employees please split these fully out in Section H. D PREVIOUS COVER Previous extent of coverage where medical cover has been purchased before Limit Excess No cover previously purchased Did the cover include spouses and/or dependents YES NO Any other details:

6 Sure Family E CLAIMS RECORD Please provide particulars of all accident, sickness claims which occurred during the past 5 years, if the space is insufficient please produce an electronic report which includes the data headers as set out below. Please state for each of the 5 years how many crew were employed. (Formats should be Excel or earlier,.csv or.txt formatted files). Note: Has an excess or deductible been employed in the case of the above claims experience, and is so please show the amount and how it has been utilised over this claims reporting period. If you have ever purchased cover for spouses &/or dependents please also state their claims experience for the same period. Year Type Total Claims Cost Total Number of Claims Claims File Open/Closed Year Type Nationalities Typical Limit Typical Excess State Nº of Insured Covered during this period Please split the calendar year figures if possible, by crew type - officers or crew and by their nationality.

7 Sure Family G DECLARATION & SIGNATURE Please sign this declaration once you have read it. If you are unsure as to whether any information should be given, you should provide it. I /We declare that: I/We will inform the insurer of any changes that occur before this insurance commences. I/We understand that failure to do so may result in this insurance being declared void and that a claim for the benefits may not be paid. To the best of my knowledge and belief, all the statements made, which includes anything I/we have said, have been recorded accurately in this application, or are as attached and are true and complete. This disclosure will form the basis of the contract. I/We understand that this contract will renew at the end of each 12- month period subject to the terms and conditions of this insurance. I understand that underwriters reserve the right to modify the terms, conditions or premium of the policy if a variation of twenty percent (20%) or more occurs from that stated in this proposed form at any time during the life of the contract; or that the percentage number of lives contributed to the total by any one given nationality. I/We agree that a copy of the agreement given in this declaration will have the validity of the original. Data Protection Act 1998 As this contract is governed by the laws of England and Wales we are required to set up and administer your policy under the Data Protection Act. Therefore the Insurers (acting as the Data Controller) and the scheme administrator, Compass Underwriting Limited (as the Data Processor), will hold and use information about the insured person supplied by you and by medical providers, if applicable. Information may be disclosed to regulatory bodies for the purposes of monitoring and/or enforcing compliance with any regulatory rules/codes and crime prevention and sanctions monitoring. Information may be transferred to other countries including those outside the European Economic Area. To assess the terms of the policy or handle claims which arise, it may be necessary to collect data which the Data Protection Act defines as sensitive (such as medical history, criminal convictions or employment records). Data protection laws impose specific conditions in relation to sensitive information including, in some circumstances, the need to obtain explicit consent from the insured person before this sensitive information is processed. Without this consent it will not be possible to offer this insurance or pay any claim. By signing this Declaration, you hereby confirm your consent on behalf of your employee, the insured person, to such use of their personal data. Important Notes: This policy will be governed by the laws of England and Wales unless you and we have agreed otherwise. You are reminded that you must inform us within 30 days if you, or the individual registered owners of individual vessels within your fleet, cease to trade or begin winding up procedures at any time during the period of this insurance. To sign this form you must be an officer or director of the company. Signature &/or Company Stamp Name Position Date

8 Sure Family H SECTION FOR ADDITIONAL INFORMATION Question No. Additional Information

9 Sure Family IMPORTANT NOTES The insurer has a confidentiality policy in place which means that your employees and their families medical information is held securely and access is limited to authorised individuals only. You are entitled to ask for a copy of the terms and conditions of your insurance at any time and can request a copy of your propsal form. The policy will be governed by the laws of England and Wales unless you and we have agreed otherwise. WHAT TO DO NOW Once you have completed this document please ensure that you have signed the declaration in Section G. Please then send back to us: sure Insurance Services Limited 50 Mark Lane London EC3R 7QR or by to: info@crewsure.com Telephone number +44 (0) sure Insurance Services Ltd is registered in England and Wales No sure Insurance Services Ltd are an Appointed Representative (FCA Ref ) of Compass Underwriting Ltd who are authorised and regulated by the Uk s Financial Conduct Authority under Reference