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Name of vessel   Company Name
Vessel cruising limit   Building Name & Number
Geographical limits   Street
Telephone   City
Email   Zip Code
Total Number of Crew   Country



Position Title Surname Forname Gender Nationality
Country of Residence Date of birth Annual Salery Accident Limit
Declaration-please read carefully and complete
This application form will be the basis for the contract between the Insured and the Insurer.  Any employee(s) proportion of the Policy Premium will be paid in full by the Insured, without recovery from the employee(s).  All Insured persons meet the eligibility criteria for the scheme.
Entry onto the policy will be with one of the following underwriting methods:
Moratorium It is understood that the policy will not cover any investigation and/or treatment for any illness related medical condition for which the persons to be insured underwent treatment, sought medical advice or were aware of symptoms within the two years before the start date of this policy.
Data Protection Act 1998
I/we confirm and agree that information about me/us and this application form may be retyped on paper and computer by C.J. Coleman & Company Limited and/or The Spectrum IFA Group and its subsidiaries and used:
A)  By Certain Underwriters at Lloyd’s and other businesses that provide insurance services relating to the policy as may be necessary for the administration of my/our policy.  I/we agree that it may be necessary for Certain Underwriters at Lloyd’s to obtain and use sensitive personal information about me/us.
B)  To provide information about me/us (whether provided in the application form or any claim form) to other insurers for the prevention of fraud and to other third parties for the purpose of administration of their policy or any claim.  Details of such third parties and other insurers will be made available on request.