GSIS insurance application form for hull

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Tel. No.

Name Of Vessel

Former Name of Vessel (if any)

Registered Owner of Vessel

Hull & Machinery Insurance Questionnaire
1. Brief Company Profile
2. Shipping experience of management and employees.
3. Number of vessels owners operate and how these are utilized
4. Principal and secondary business of the owner
5. Please provide copy of vessel’s latest Conditions/Valuation Survey Report
Particulars of the Vessel
◦ Self – propelled

◦ Passenger



◦ Yacht

◦ Fishing Boat ◦Barge
Type of Vessel
◦ Self – propelled ◦ Passenger ◦Cargo ◦Tugboat
◦ Yacht
Year Built

◦ Fishing Boat
Place Built


Place Vessel is Registered

Registered Tonnage


Place Vessel is Dry-docked

Nationality of Crew

Type of Hull
◦Fiber Glass
◦Ferro Cement




Last Dry-docked

Number of Crew

(use extra papers to provide full description)

A. Hull
B. Machinery ( Includes propelling machinery, electric
motors, auxiliary, such as pumps, deck machinery, such as
steering gear, winches and windlass, and other necessary
machinery of similar kind installed on board)
C. Present Market Value
Value to be Insured


Term of Insurance

Required Conditions of Insurance
◦ Institute Time Clauses – Hulls 1.10.83 (Clause 280)
◦ Institute Time Clauses – Hull Total Loss, General Average and 3/4ths Collision Liability 1.10.83 (Cl. 284)
◦ Institute Time Clauses – Hulls Total Loss Only 1.10.83 (Clause 289)
◦ Institute Time Clauses – Port Risks 20.7.87 (Clause 311)
◦ Institute Time Clauses – Hulls Port Risks including Limited Navigation 20.7.87 (Clause 312)
◦ Institute Voyage Clause – 1.10.83 (Clause 285)
◦ Institute Fishing Vessel Clauses 20.7.87 (Clause 346)
◦ Institute Speedboat Clauses 1.11.85 (Clause 333)
◦ Institute Protection and Indemnity Clauses Hulls – Time 20.7.87 (Clause 344)
◦ Institute Clauses for Builders’ Risks 1.6.88 (Clause 351)

Trade Vessel is Engaged

Area/s Vessel will Trade

Name/s of Vessel under the same Ownership

Previous Insurers (for the last 3 years)

Loss Experience (for the last 3 years)

Submitted & Certified by:

Official Designation:

Signature over printed name
Contact No.

(use extra papers to provide full description)