1

Personal Details

2

Risk Details

3

General Policy Details

Personal Details

Male Female

Contact Details

Particulars of Vessel to be Insured

Note: Ship must comform to Lloyd’s Register of Shipping standards and/or Berhan Insurance S.C. Maritime Authority standards and any other governmental regulating bodies to ensure that the vessel has necessary structural strength for assigning a load line, and the issuing of a safety construction certificate.

Type of Fire Extinguishers and Number Carried

Captain/Master/Pilot Detail

Captain/Master/Pilot 1

Crew Details

Crew 1

Limits of Liability(ETB)

Limit of Indemnity For any One Accident

Maintenance Of The Vessel (Laid up, In Commission, Overhauling)



General Policy Details

Has any insurance company ever

Insurance and Loss History

Please provide below information on any insurance claims you have reported in the last 3 years

Add Loss

DECLARATION AND CONSENT | Please Read Carefully *

I the undersigned declare that the vehicle(s) described (is/are) in good condition and will continue to be maintained and I hereby warrant that the above statement and particulars are true and I hereby agree that declaration shall be deemed to be of a promissory nature and effect and the basis of the contract between me and the Company and that I have not withheld any important information which should be communicated to the Company and that I am willing to accept a policy subject to the terms, conditions and exceptions therein and to pay the premium agreed upon.

CREDIT INFORMATION | Please Read Carefully *

I/we do hereby confirm that I/we have authorized Berhan Insurance S.C. to share my/our credit information and to access my/our credit profile from Credit Reference Bureau (C.R.B)