CONSORTIUM FOR

WRECK REMOVAL including POLUTION LIABILITY INSURANCE

(new cwri form)

APPLICATION FORM
(one form per vessel)

To/Kepada:
[Member Consortium]

Address/Alamat:
[Member Consortium Address],

in their capacity as underwriting agents for Consortium for WRI (hereinafter called:
“the Consortium Member”).
Dalam kapasitasnya sebagai underwriter untuk Konsorsium WRI (selanjutnya
disebut: Anggota Konsorsium)

The undersigned herewith confirm acceptance of the Consortium’s terms and

conditions, as agreed. The content of the Consortium’s completed questionnaire,
information provided by the Assured and/or his broker during the quotation or
renewal stage of the insurance contract will form part of the insurance contract.
Yang bertanda tangan di bawah ini mengkonfirmasi penerimaan syarat dan
ketentuan Konsorsium, sebagaimana disetujui. Kuesioner Konsorsium yang telah
diisi, informasi yang diberikan oleh Tertanggung dan / atau pialangnya selama
tahap Penawaran atau pembaruan kontrak asuransi, akan menjadi bagian dari
kontrak asuransi.

Existing CWRI : Misal: XXX – XXX – XXXX – XXXX

Certificate of If yes, Reload expiring Data  perfectly mirroring to
Insurance (CoI) existing entry for further verification
Sertifikat CWRI saat
ini Entry ke-XXX refer ke nomor certificate existing

Date of Inception : Dd-mm-yyyy

Tanggal Mulai
Asuransi

Type of insurance : Wreck Removal : Yes / No

Jenis Asuransi Penyingkiran Rangka Kapal

Pollution : Yes / No
Polusi
PART 1 : DETAIL OF VESSEL, CREW, AND SURVEY
Vessel ID: V000001
Nomor identitas
kapal
Name of Ship: : Free text
Call Sign: Free text
Page 1 of 4
Type: compulsory
IMO Number: Free text
Classification Free text
society:
GT/GRT: compulsory, in Tonnage
Maximum Load: Free text, compulsory if passanger ship.
Year of Built: compulsory
Flag State: compulsory
Port of Registry: compulsory
Number of Officers,
and Nationality: Free text

Number of Crew and

Nationality: Free text

Vessels market
value (USD) Free text

Vessels insured Free text

Value (USD)
Last Special Survey : Yes/No
past (month/year)
If YES, YEAR : January / 2020

If YES, copy of Classification Society’s written evidence

of outstandings to be enclosed herewith

Attachment – max 20mb file pdf

Outstanding class Free text

items

Last P. & I. or CWRI Yes/No

condition survey
(month/year) If YES, YEAR : January / 2020

If YES, copy of P. & I. Club’s / CWRI written evidence of

outstanding defects to be enclosed herewith (Survey
report)

Attachment – max 20mb file pdf

Outstanding defects
Free text

Vessel forms part of Yes/No

a fleet If YES, the insurance will be subject to the Company’s
terms about Fleet Insurance
Name of mortgagee Free text
(if applicable)
H&M Covered*) : Yes/No
Condition Survey : Yes/No
Report
If YES, YEAR : January / 2020

If YES, the insurance will be subject to the Company’s

terms about Condition Survey Warranty Provision

PART 2 : DETAIL OF THE ASSURED (REGISTERED OWNER)

Page 2 of 4
Name of individual
involved with
insurance and claims

Person in charge:
Designation: Free text, compulsory
Email Address: Free text,
Free text, compulsory

full legal title and Free text, compulsory, with PT

trading name of the
Assured *)
Full address Free text
City incl. Postal code Free text

Bank Details Name of Bank Free text

BIC Number Free text
IBAN Number Free text
Bank Account: Free text
PART 3 : DETAIL OF THE SHIP MANAGER
Is ship registered Yes/No,
owner as well as if yes then reload Data Part 1
ship manager?
Name of individual
involved with
insurance and claims

Person in charge:
Designation: Free text, compulsory
Email Address: Free text,
Free text, compulsory
Company name Free text,
Full address Free text,
City incl. postal Free text,

PART 4 : DETAIL OF OTHER ASSUREDS (IF APPLICABLE)

Name of individual
involved with
insurance and claims

Person in charge:
Designation: Free text, compulsory
Email Address: Free text,
Free text, compulsory
Company name Free text,
Full address Free text,
City incl. postal Free text,

Assured to be Joint Assured

included in insurance Co-assured/join assured
certificate as Charterer
Mortgage
Other Assured

PART 5 : INVOICING
Invoice for CWRI Assured
insurance to be sent Ship Manager
to: Other assured
Page 3 of 4
(Please tick box)

Kalau ditagih ke bank, maka hrs ada button (other

assured).

Format Billing: USD or IDR? Tick One, master ROE

sendiri?
Konsensus keuangan punya ROE bulanan sendiri.

PART 6 : BLUE CARD 

Name of issuing flag CLC Card: Indonesia
state Bunker Blue Card: Indonesia
Wreck Removal Blue Card: Indonesia

INI MESTINYA MASTER DATA.

Kalau GRT > 1000 GT : BBC
Kalau Load Cap > 2000 GT : CLC
Kalau GT > 300 : WR Blue Card.

PART 7 : DECLARATION

I declare that the information supplied by the company

is true and correct and any wrong information given can
render the agreement void at the option of the
Consortium

Date of application DD MM YYYY

SIGNED BY ini refer ke INVOICING (Step 5)

By Default isi data assured (part 1)

Signed by
Free text
On behalf of
Free text
Capacity/Designation
Free text
Signature/Company
stamp

PRINT? YES/NO (pdf)

Page 4 of 4