Stevedores Application

First Name

Last Name

Business Name

street address

address line 2

City

state

zip code

Phone Number

Effective Date Needed

Number of Employees

Year Business Started

% of Subcontracting

Physical location street address

address line 2

City

state

zip code

% steel vessel work?

% fiberglass vessel work?

% wood vessel work?

average value of vessel worked on

% ferro cement vessel work?

% aluminum vessel work?

maximum value of vessel worked on

Claims history

describe any non-marine work and revenue applicable

$ engine work

$ rigging work

$ fiberglass work

$ welding work

$ diving work

$ other work

$ electrical work

$ painting work

$ carpentry work

$ detailing work

$ canvas work

Describe other work

Current Insurance Company or companies you are working with

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