This worksheet is to be used by WQIS Brokers to submit underwriting information to the underwriting department to obtain a quotation from WQIS.

Applicant Information:
Assured Name : City :
Address : State :
Zipcode :


General Underwriting Information:
1. Limit requested :
* All values are in US Dollars
2. Please advise trading limits:
Attach an explanation if it varies by vessel: *
* Acceptable File Types: doc, xls, csv, pdf, wpd
3. Does this policy require the California and/or Alaska endorsements?
Yes No
4. What is the principle business of the applicant?
5. What pollution claims have the Applicant paid and what claims are outstanding over the last five years?
6. Does the Applicant own or operate any vessels not being offered to be insured by WQIS?
  Yes No
7. Has the Applicant ever been denied coverage or had their insurance cancelled?
  Yes No
8. Vessel information (use for single vessels.for multiple vessels, see # 10)
Vessel name :
Vessel identification number (VIN) :
Gross tonnage/ ITC Tonnage :
A description of the vessel :
Dimensions of the vessel :
Horsepower, if self-propelled :
Does the vessel have spuds?
Vessel fuel capacity :
(also fuel on non-self-propelled vessel)
Type of cargo carried :
Cargo capacity :
(including the number of containers, if any)
Hull construction : (both type and material)
Hull value :
Date built/ rebuilt :
Is the vessel in class?
Vessel's flag if not U.S :
COFR applicant Name (if applicable) :
Blue Card Request Information (only if applicable)  
Registered Owner / Address (if different from above)
IMO Number :
Call Sign and/or Distinctive Numbers :
Port of Registry :
9. If there are multiple vessels, please attach a complete listing of all vessels requiring insurance providing the above information. *
* Acceptable File Types: doc, xls, csv, pdf, wpd
We recognize that responses to all these questions would contain a lot of information and such information may not always be available. Of course, if an Applicant has 300 deck barges, we would not expect that these questions would be answered for each vessels, but rather that common sense would dictate the most logical information to provide. While material facts must be disclosed to WQIS, we would expect that the broker would provide the necessary information without going overboard!
10. Who is the current hull underwriter(s): (if multiple, list leader)
and what limits are purchased :
11. Who is the current P&I underwriter(s): (if multiple, list leader)
and what limits are purchased :
12. Please provide any other general comment you would like to make :


* Mandatory Fields
Date Submitted * :
Broker Name * :
Broker Address * :
Broker City and State :
Broker Zip code :
Broker Phone * :
Individual Broker :
First Name * :
Last Name * :
Contact Email * :
Have you done business with us before? * : Yes No
If No please contact our Underwriting Department?