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Application
for
MOPS
Marine License
Insurance
You owe it to yourself to
obtain a no-obligation rate quote from North America's original
and foremost marine license insurance program - the one
and only MOPS.
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Simply complete
all of the fields below and click on SUBMIT.
Or, you or your agent may contact MOPS at 1-800-782-8902,
ext. 3302 or ext. 3608.
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Your
U.S.C.G License Serial Number
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Issue
Date
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MM/DD/YY |
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Expiration
Date
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MM/DD/YY |
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Your
preferred starting date is
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MM/DD/YY
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1.
Name of Applicant
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Last.........................First.........................MI |
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2.
Street
Address
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P.O.
Box
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City
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State
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Zip
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Home
Tel. No.
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Cell
Tell. No.
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E-mail
Address
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What is your current Sailing Grade?
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| 4. |
Do you serve aboard a tug?
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Yes
No |
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you serve aboard a towing vessel? |
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Yes
No |
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Is your U.S. Coast Guard license endorsed for state pilotage?
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Yes
No |
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| 6. |
If you are currently working exclusively as a pilot, please indicate
what type:
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Federal
State |
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If
you checked State license, please provide:
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MM/DD/YY |
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State
of Issuance |
Serial
Number.. |
Date
of Issuance
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| 7. |
Please provide name of current employer:
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| 8. |
Under the authority of your current U.S.C.G. license, are you involved
in the delivery or transportation of private or
corporate yachts?
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Yes
No |
| 9. |
a) Would you like to insure your full monthly compensation?
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Yes
No |
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b)
If Yes, please provide your TOTAL MONTHLY COMPENSATION* (base wages,
average overtime and vacation pay):
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$
(*Total
Monthly Compensation = Annual Salary Divided by 12) |
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c)Would you like to insure
PART OF YOUR MONTHLY COMPENSATION?
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Yes
No |
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d)
If Yes, please indicate monthly compensation you would like to insure:
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$
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| 10. |
Have you ever been involved in or are you aware of any incident or
incidents which occurred while sailing under your Marine License(s)
which could have or may result in action against your License(s)?
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Yes
No |
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YES, please explain: |
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you have a copy of MARINE CASUALTY REPORT(S)? |
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Yes
No |
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| 11. |
Have
you ever been involved in a marine incident(s) which resulted in,
or could have resulted in, Federal, State or local CRIMINAL CHARGES
being brought against you?
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Yes
No |
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| 12. |
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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Yes
No
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13.
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Has your Marine License(s) ever been revoked, suspended or reduced
in grade?
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Yes
No
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14.
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Have you ever been named in a CIVIL LAWSUIT resulting from an incident(s)
occurring while sailing under your Marine License(s)?
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Yes
No |
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YES, Please explain: |
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| 15. |
Have you ever been named in a CIVIL PENALTY action resulting from
an incident(s) occurring while sailing under your Marine License(s)?
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Yes
No
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Have you ever been ordered to pay a CIVIL PENALTY FINE?
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Yes
No |
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Please
provide fine amount
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$
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COVERAGES
REQUESTED
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BASIC
COVERAGES
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LIMITS
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Comprehensive
License Defense
Loss of Income:
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Unlimited
As declared in questions #8b or 8d.
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Professional
Instruments & Equipment |
$3,000
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Please list all items for which coverage is requested. Failure to
provide list in advance voids coverage.
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OPTIONAL
COVERAGES
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LIMITS
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Civil
Legal Defense:
(If
Yes, please check coverage limit requested)
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Yes
No
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$.......$50,000
$.......$75,000
$.....$100,000
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Professional/Civil
Liability:*
(If
Yes, please check coverage limit requested)
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Yes
No |
$.....$100,000
$.....$250,000
$.....$500,000
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*All
applicants for Professional/Civil Liability Coverage must have a
minimum limit of $100,000 Civil Legal Defense Coverage.
Professional/Civil
Liability may NOT be Available to Those Mariners Involved in Yacht/Recreational
Craft Delivery, Some Types of Private Charter Work and/or On-Water
Instruction. All Professional Liability Quotes Released at Underwriters
Discretion.
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Criminal
Legal Defense (Oil Pollution Only):
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Yes
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$.......$25,000
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Civil
Penalties Legal Defense:
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Yes
No |
$.......$10,000
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UPON
REVIEW AND APPROVAL OF THIS APPLICATION, THE UNDERWRITER WILL CALCULATE
AN ANNUAL PREMIUM BASED UPON THE INFORMATION LISTED BY THE APPLICANT
HEREIN.
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DECLARATION
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By
checking this box, I
hereby warrant that the above particulars and statements are that I
have not omitted or misstated any material fact and 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.
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This
application for MOPS Marine License Insurance is copyrighted and material
appearing within may not be reproduced in any form without the written
permission of Lancer Insurance Company.
©Lancer Insurance Company 2007
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MOPS
Marine License Insurance
P.O.
Box 9004, Long Beach, N.Y. 11561-9004
TEL. (800)782-8902 ext. 3302 or ext.3608
TEL. (516)431-4441 – Fax (516)431-0796
www.mopsmarinelicenseinsurance.com
Member
Company: Lancer Insurance Group
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