Welcome to MOPS Marine License Insurance

	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.
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.

Your U.S.C.G License Serial Number

Issue Date

MM/DD/YY

Expiration Date

MM/DD/YY

Your preferred starting date is

MM/DD/YY

1. Name of Applicant

Last.........................First.........................MI

2. Street Address

P.O. Box

City

State

Zip

Home Tel. No.

Cell Tell. No.

E-mail Address

What is your current Sailing Grade?

Do you serve aboard a tug?

Yes No

Do you serve aboard a towing vessel?

Yes No

Is your U.S. Coast Guard license endorsed for state pilotage?

Yes No

If you are currently working exclusively as a pilot, please indicate what type:

Federal State

If you checked State license, please provide:

MM/DD/YY

State of Issuance

Serial Number..

Date of Issuance

Please provide name of current employer:

Under the authority of your current U.S.C.G. license, are you involved in the delivery or transportation of private or
corporate yachts?

Yes No

a) Would you like to insure your full monthly compensation?

Yes No

b) If Yes, please provide your TOTAL MONTHLY COMPENSATION* (base wages, average overtime and vacation pay):

$ (*Total Monthly Compensation = Annual Salary Divided by 12)

c)Would you like to insure PART OF YOUR MONTHLY COMPENSATION?

Yes No

d) If Yes, please indicate monthly compensation you would like to insure:

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)?

Yes No

If YES, please explain:

Do you have a copy of MARINE CASUALTY REPORT(S)?

Yes No

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?

Yes No

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?

Yes No

13.

Has your Marine License(s) ever been revoked, suspended or reduced in grade?

Yes No

14.

Have you ever been named in a CIVIL LAWSUIT resulting from an incident(s) occurring while sailing under your Marine License(s)?

Yes No

If YES, Please explain:

15.

Have you ever been named in a CIVIL PENALTY action resulting from an incident(s) occurring while sailing under your Marine License(s)?

Yes No

16.

Have you ever been ordered to pay a CIVIL PENALTY FINE?

Yes No

Please provide fine amount

COVERAGES REQUESTED

BASIC COVERAGES

LIMITS

Comprehensive License Defense
Loss of Income:

Unlimited
As declared in questions #8b or 8d.

Professional Instruments & Equipment

$3,000

Please list all items for which coverage is requested. Failure to provide list in advance voids coverage.

OPTIONAL COVERAGES

LIMITS

Civil Legal Defense:
(If Yes, please check coverage limit requested)

Yes No

$.......$50,000
$.......$75,000
$.....$100,000

Professional/Civil Liability:*
(If Yes, please check coverage limit requested)

Yes No

$.....$100,000
$.....$250,000
$.....$500,000

*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.

Criminal Legal Defense (Oil Pollution Only):

Yes No

$.......$25,000

Civil Penalties Legal Defense:

Yes No

$.......$10,000

How would you like your quote sent to you?
	Electronic Quote (via E-mail)	Regular Mail

Are you interested in hearing about Travelers Ocean Marine Total Account Solution? (Click here for more information.)
	Yes, please send my contact information to a Travelers representative	No, I am not interested in Travelers at this time.

How did you hear about MOPS Marine License Insurance?
	Professional Mariner Magazine	Workboat Magazine
	Internet	Friend/Colleague
	Tell-A-Mate:	Other:

UPON REVIEW AND APPROVAL OF THIS APPLICATION, THE UNDERWRITER WILL CALCULATE AN ANNUAL PREMIUM BASED UPON THE INFORMATION LISTED BY THE APPLICANT HEREIN.

DECLARATION

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.

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

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