All requests for quotations should be submitted to C Support Limited by the client or their chosen intermediary.

1. Name of Client Group

(Registered Owner and Manager and Parent Company, address and contact details):

2. Vessel details:

Name of Ship(s) to be Covered:

Year built:

Type:

Tonnage:

Flag of Vessel:

Classification Society:

IMO Number:

3. Name of Protection and Indemnity Insurers and Brokers

Name of Brokers:

Name of P&I Insurers:

4. Name of Hull and Machinery Insurers and Brokers

Name of Brokers:

Name of H&M Insurers:

5. Type of trade

(e.g. spot/period/time charter/geographical trading etc) :

6. Name of Current or Prospective Charterer

Name:

Duration and terms of fixture:

Country of Domicile:

7. Details of any claims or disputes brought by or against the client or any affiliated company within the last 12 months

Details:

This form should be read in conjunction with the C SUPPORT Terms and Conditions.

The agreed non returnable annual fee is payable on acceptance by C Support Limited of this Proposal Form.

This Proposal Form is an integral part of the C SUPPORT product package and should be answered accurately and truthfully. Any misrepresentation or omission could invalidate the extent of the C SUPPORT product.

This is not an Insurance Policy and you are advised to take professional advice if you are unclear about the nature and scope of this product.

We are not a law firm nor an insurance company and we are not regulated by the Financial Conduct Authority (FCA). Although our staff are legally trained we may seek if deemed by us to be appropriate, further external legal advice at any time at our expense when advising within the terms of this product. See our full Terms and Conditions. By signing this Proposal Form you are deemed to have read, understood and agreed our Terms and Conditions including any limitation as to our liability to you.

Name:

Capacity in Which Signing:

Email:

Contact Tel No:

We Agree:

On-line submission of this form shall be deemed to have been signed by the individual on behalf of the company nominated. We have read, understood and agreed the Terms and Conditions of trade.