Vessel Name and No.                                                                                 

VHF Call #                                                                Date                            

Owner                                                                    Phone No.                     

Address                                            City               State       Zip               

Operator                                                                                  Age            

Experience (# Years, Type of Vessels, Areas and Fisheries)                  

Alternate Operator                                                                 Age             

Type of Fishing Operation                                                                          

Waters to be Navigated                                                                             

                                                                        Est. Crew
No. of Crew in Each Fishery                         Share for LL                         

Vessel:  Market Value          Replacement Value          Gross Tonnage      

Year Built        Builder                                          Hull Material                   

Length            Beam                Draft                  No. of Engines                    

Engines:  Diesel   Gas     Horse Power      Year Built          Mfg.              

Mortgage on Vessel:  Amount            With (Name & Address)                 

Amount of Indemnity Requested    

                                  $100,000         

                                  $200,000           

                                  $300,000         

Excess Insurance Requested?             Oil Pollution Coverage?  Y  N

Operator's Previous P & I Loss Experience                                                

Alternate Operator's Previous P & I Loss Experience                               

Life Raft?            Survival Suits?              Bilge & Fire Alarms?                

Who carries Hull Insurance?                                                                        

Name of Current/Previous P & I Insurer                     Present Insurance Expires                    

Enclose a Recent Survey and Photograph:  Note any recommendations complied with                                                                                                    

Recommendations from Reserve members, if known:                                

Other Information                                                                                          

I, the undersigned vessel owner, hereby apply for membership or renewal of existing membership in the MARINE SAFETY RESERVE in order to provide my vessel with necessary indemnity for certain losses.  As a member of the RESERVE, I agree without reservation, to be bound by the attached Articles of Association of the organization which I have read.  I acknowledge that my indemnity protection automatically ceases if I have not paid all dues owing to the Reserve on the due dates set forth in the Articles or if I have not paid any special assessments by the date set by the Board of Trustees.  I make the foregoing application and agreements on behalf of myself and any present or future partners or co-owners of my vessel, warranting my authority to bind such partners or co-owners.

SIGNED:                                                           DATE: