MA-528 Application for War Risk Insurance

U.S. Department of Transportation
Maritime Administration

OMB Control No. 2133-0011
Expiration Date: 06/30/2017

Application
for
War Risk Insurance

Binder No. WR- ______________
App No. ____________________
CRV No. ____________________

A federal agency may not conduct or sponsor, and a person is not required to
respond to, nor shall a person be subject to a penalty for failure to comply
with a collection of information subject to the requirements of the Paperwork
Reduction Act unless that collection of information displays a current valid
OMB Control Number. The OMB Control Number for this information
collection is 2133-0011. Public reporting for this collection of information is
estimated to be approximately 95 minutes per response, including the time for
reviewing instructions, completing and reviewing the collection of
information. All responses to this collection of information are voluntary.
Send comments regarding this burden estimate or any other aspect of this
collection of information, including suggestions for reducing this burden to:
Information Collection Clearance Officer, Maritime Administration, MAR-390,
1200 New Jersey Avenue, SE, Washington, DC 20590.

Pursuant to Title XII of the Merchant Marine Act, 1936, as amended, and in accordance with all applicable
provisions of law and subject to all limitations thereof, application is hereby made for WAR RISK INSURANCE as
follows (check all that apply):

War Risk
Disbursements
Endorsement

War Risk Hull
Insurance

War Risk P&I
Insurance

Second Seamen's War Risk
Insurance (1955)

Name of Assured(s)

Identify with a letter following the name whether assured is owner (A), charterer (B), mortgagee (C) or other (D).

Address of Assured(s) (Number, Street, City, State, Zip Code)

Has mortgagee been
notified of this
application?
Loss, if any, payable to

Yes

No

Name of Mortgagee (if applicable)

(See Appendix A for hull and P&I) or order.

Vessel Name(s)

Form MA-528
(Rev. 7-2011)

Official No.

Not required

(See Appendix B)

Flag

Gross Tonnage

Date Built

HULL -- Sum insured (See Appendix B), but in the event of damage to or actual or constructive total loss of the
vessel, the insured value will be not in excess of $_____________ *, which latter amount is the stated valuation
of that vessel as determined by the Secretary of Transportation in accordance with section 1209(a), Title XII of
the Merchant Marine Act, 1936, as amended. This insurance does not cover loss of disbursements provided
herein below, as additional coverage, as a consequence of the actual or constructive total loss of said vessel. It
is understood that, with respect to damage to or actual or constructive total loss of the vessel, this insurance
shall not exceed the "sum insured" or the "stated valuation," whichever is the lesser amount.
* If this valuation is not inserted when the binder is issued, it will be published in the Federal Register pursuant to 46 CFR 309, as amended
from time to time.

DISBURSEMENTS -- (consumable and subsistence stores, slop chests, bar stock and bunker fuel) -- Insured
for (See Appendix B) _____________ dollars against the risks of loss as a consequence of the actual or
constructive total loss of the vessel insured hereunder. This insurance is optional and is provided applicants for
hull insurance as additional coverage. In the event of loss, payment of claim shall be limited to the actual value
of the disbursements loss but not exceeding the amount so insured.
WAR RISK PROTECTION AND INDEMNITY INSURANCE -- Sum to be insured as specified for each vessel
listed in Appendix B, but not exceeding $750 per gross ton of the vessel.
SECOND SEAMEN'S WAR RISK INSURANCE (1955) -- Loss, if any, payable in accordance with and in the
amount specified in the applicable provisions of the Second Seamen's War Risk Policy (1955), or as modified by
shipping articles, collective bargaining agreements or other applicable employment agreements which are in
effect as of the date of a casualty involving the subject vessel. Upon the attachment of this binder, the number
of crew members and modified benefits payable as of that date shall be declared immediately to the
Underwriting Agent. Any subsequent changes will be likewise declared.
To attach automatically upon and simultaneously with (a) the outbreak of war (whether there be a declaration of
war or not) between any of the following countries: United States of America, United Kingdom, France, the
Union of Soviet Socialist Republics, or the People's Republic of China; or (b) upon and simultaneously with the
occurrence of any hostile detonation of any nuclear weapon of war including any weapon of war employing
atomic or nuclear fission and/or fusion or other like reaction of radioactive force or matter wheresoever or
whensoever such detonation may occur and whether or not the vessel may be involved.
To terminate thirty (30) days after the outbreak of war (whether there be a declaration of war or not) between
any of the aforesaid countries.
Terms and Conditions: Subject to form of policy prescribed by the Maritime Administrator, acting for the
Secretary of Transportation. The category (one only) of eligibility under which application is made must be
designated.
(a)
A vessel registered, enrolled or licensed under the laws of the United States; any tug or barge or other
watercraft (documented under the laws of the United States, or undocumented) owned by a citizen of the United
States, used in essential water transportation within the territorial waters of the United States; and U.S. citizenowned watercraft in the fishing trade or industry, except when used exclusively in or for sport fishing.
(b)(1)
A foreign-flag vessel under Panamanian, Honduran, Bahamian, Republic of the Marshall Islands, or Liberian
registry, 1,500 gross tons and over, self-propelled, and not over twenty years of age (unless authorized by the
Maritime Administration), which is subject to an unqualified Contract of Commitment with the United States in
form as required by the Maritime Administration, and which is owned by a U.S. corporation, or a foreign
corporation in which a majority of the stock is owned and controlled by U.S. citizens, whether direct or through
intervening corporations, foreign or domestic. Where such intervening corporations are foreign, the ultimate
majority ownership and control of the stock of such corporations must be vested in a citizen or citizens of the
United States as defined in section 1201(d), Merchant Marine Act, 1936, as amended.

Form MA-528
(Rev. 7-2011)

(b)(2)
A foreign-flag vessel under Panamanian, Honduran, Bahamian, Republic of the Marshall Islands, or Liberian
registry, 1,500 gross tons and over, self-propelled, and not over twenty years of age (unless authorized by the
Maritime Administration), which is subject to an unqualified Contract of Commitment with the United States in
form as required by the Maritime Administration, and which is owned by a foreign corporation which is not
directly or beneficially owned by U.S. citizens or corporations, but which vessel is under a long-term charter or
other long-term contract covering the use of the vessel on terms deemed by the Maritime Administration to
subject the vessel to U.S. control in the event of emergency. The charterer of such a vessel must be either a
U.S. corporation or a foreign corporation in which a majority of the stock is owned and controlled by U.S.
citizens, whether direct or through intervening corporations, foreign or domestic. Where such intervening
corporations are foreign, the ultimate majority ownership and control of the stock of such corporations must be
vested in a citizen or citizens of the United States as defined in section 1201 (d), Merchant Marine Act, 1936, as
amended.
(c)
All other vessels will be insured at the sole discretion of the Maritime Administrator, but only when engaged in a
service which has been determined by the Maritime Administrator to be in the interest of the national defense or
the national economy of the United States.
It is warranted, as to a vessel in any of the above categories, that at all times during the binder period or any
period of insurance attaching thereunder, the vessel will comply with Department of Commerce/Transportation
Orders T-1 and T-2 (44 CFR Parts 401,402, and 403) or any modification thereof so long as they remain in
force.
Warranted, as to a vessel in any eligible category, that at all times during the binder period or any period of
insurance attaching thereunder, the vessel, by action of its owner or master, will comply with the requirements of
the vessel position reporting system as prescribed in 46 CFR 308.2(c). The applicant warrants as to a vessel in
any eligible category of the application that, without prior approval of the Maritime Administration, the vessel will
not, at any time during the binder period or any period of insurance attaching hereunder, be chartered for a
period of longer than six (6) months, or for a voyage or voyages the duration of which will probably exceed six
(6) months, to any person not a citizen of the United States, nor be chartered to such a non-citizen under a
demise or bareboat form of charter, nor be chartered to such a non-citizen for the carriage of cargoes of any
kind to or from any of the countries listed in 46 CFR 221.7 or any modification thereof so long as it remains in
force, or for use in the fisheries.
The applicant further warrants with respect to a vessel in category (a) that at and from the date of issuance of
the interim binder and for and during the term of any insurance attaching thereunder, such vessel will remain
eligible within its category.
The applicant further warrants with respect to a vessel in category (b)(1) or (b)(2) that the vessel will maintain its
eligibility within its applicable category at all times from and after the issuance of the interim binder, and will be
made available to the U.S. Government upon request in the event of national emergency pursuant to the terms
of the Contract of Commitment submitted herewith; and agrees, in this connection, that during the period of the
binder and any insurance attaching thereunder, any charter or other contract covering the use of the vessel
during such period shall be subject to termination or suspension without notice in the event the United States
requires the use of the vessel under the voluntary Contract of Commitment submitted herewith.
The applicant further warrants with respect to a vessel in category (c), that at all times such vessel will remain in
the approved service which the Maritime Administrator has found to be in the interest of the national economy or
the national defense of the United States.
In addition to the aforesaid warranties, the applicant submits certain statements, certificates and/or agreements
which are made part of the insurance application, for vessels in the following categories:
Category (b)(1) Applications: (a) An executed Contract of Commitment, in form as prescribed in Section
308.5, under which applicant commits itself to make the vessel available to the U.S. Government upon request
in the event of national emergency on the same terms and conditions as vessels owned by citizens of the United
Form MA-528
(Rev. 7-2011)

States are available for requisition, for title, or for use, in accordance with the provisions of section 902(a),
Merchant Marine Act, 1936, as amended. In the event this insurance application is determined to be ineligible
under the terms of the Maritime Administration's regulations, it is understood that the applicant will be so
advised and the executed Contract of Commitment (which is submitted in consideration of the issuance of such
insurance) shall be returned to applicant by the Maritime Administration. (b) A Certificate of Ownership and
Control by U.S. Citizens, Appendix C to this application, executed by the vessel owner establishing that the
vessel is owned by a U.S. corporation, or that a majority of the stock of the owning corporation is owned and
controlled by U.S. citizens, as defined in section 1201 (d), Merchant Marine Act, 1936, as amended, whether
direct or through intervening corporations, foreign or domestic. (c) Where such intervening corporations are
foreign, an additional Certificate of Ownership, in the form of Appendix C, shall be executed and appended
hereto, by each such corporation establishing that the ultimate majority ownership and control of the stock of
such corporation is vested in a citizen or citizens of the United States as defined in section 1201 (d), Merchant
Marine Act, 1936, as amended. (d) If prior official action or approval of the Contract of Commitment with the
United States is required by the government of the country of vessel's registry as a prerequisite to the execution
of such a contract, applicant attaches a certified copy of such official action or approval. If a vessel in
category (b)(1) attains twenty years of age on or prior to the effective date of this insurance, applicant agrees
that the subject insurance shall not attach without Maritime Administration approval.
Category (b)(2) Applications: (a) A Contract of Commitment executed by both the owner and charterer in form
as prescribed in Section 308.5, under which they commit themselves to make the vessel available to the U.S.
Government upon request in the event of national emergency on the same terms and conditions as vessels
owned by citizens of the United States are available for requisition, for title, or for use, in accordance with the
provisions of section 902(a), Merchant Marine Act, 1936, as amended. In the event this insurance application is
determined to be ineligible under the terms of the Maritime Administration's regulations, it is understood that the
applicants will be so advised and the executed Contract of Commitment (which is submitted in consideration of
the issuance of such insurance) shall be returned by the Maritime Administration. (b) A copy of the long-term
charter or other long-term contract covering the use of the vessel and all addenda, certified to be full and
complete copies (except as to rate of hire or freight). The charterer also agrees to furnish the Maritime
Administration a certified copy of any subsequent amendments to such charter. (c) A Certificate of Ownership
and Control by U.S. Citizens, Appendix C to this application, executed by the charterer establishing that it is a
U.S. corporation, or a foreign corporation in which a majority of the stock is owned and controlled by U.S.
citizens, whether direct or through intervening corporations, which may be either foreign or domestic. (d) Where
such intervening corporations are foreign, an additional Certificate of Ownership, in the form of Appendix C,
shall be executed and appended hereto, by each such corporation establishing that the ultimate majority
ownership and control of the stock of such corporation is vested in a citizen or citizens of the United States as
defined in section 1201 (d), Merchant Marine Act, 1936, as amended. (e) If prior official action or approval of the
Contract of Commitment with the United States is required by the government of the country of vessel's registry
as a prerequisite to the execution of such a contract, applicants attach a certified copy of such official action or
approval. If a vessel in category (b)(2) attains twenty years of age on or prior to the effective date of this
insurance, applicants agree that the Subject insurance shall not attach without Maritime Administration approval.
Category (c) Applications: A copy or the statement of vessel's service previously submitted by the applicant,
which was the subject of a finding by the Maritime Administrator that such service is deemed to be in the interest
of the national defense or the national economy of the United States.
Warranted free from any claim for loss, damage or expense covered under any commercial policy in effect for
the benefit of the assured.
Warranted free from any claim for loss, damage or expense which is or could be covered by a commercial war
risk policy containing the American Institute Hull War Risk and Strikes Clauses (including Automatic.
Termination and Cancellation Provisions) for attachment to American Institute Hull Clauses, December 1, 1977.
Applicant also attaches appropriate vessel data as required in 46 CFR 309.8.
The warranties and representations in this application, which are made in consideration of the issuance of the
insurance (above) indicated, shall become a part of this application and be deemed incorporated in the binder
and in any insurance policy issued thereunder, to the same extent as though set out in full in such documents.

Form MA-528
(Rev. 7-2011)

Binding Fee (Not Returnable)
U.S.-Flag Vessels
Type of
Insurance

Foreign-Flag Vessels**

Under 500
GRT

500 GRT
and Over

LASH or
Similar
Barge

Under 500
GRT

500 GRT
and Over

LASH or
Similar
Barge

$25

$100

$100

$50

$200

$200

Hull*
P&I

$100

$100

$200

$200

nd

$75

N/A

$150

N/A

2 Seamen’s

N/A = Not Applicable
* There is no separate fee for disbursements endorsement.
** Payable in U.S. funds.
Check payable to the order of "Maritime Adm.-Transportation," enclosed herewith.
Rate of premium to be fixed by the Maritime Administrator, acting for the Secretary of Transportation.
Dated ______________________________ 20_____
Applicant(s) _________________________________
By: _______________________________________
Authorized Signature

_______________________________________
By: _______________________________________
Authorized Signature

Binder to be sent to:
Name __________________________________________
Address ________________________________________
________________________________________

Application on category (a) vessels to be submitted, with required attachments, to:
American War Risk Agency
14 Wall Street
New York, NY 10005
Applications on all other vessels to be submitted with required attachments, to:
Attn: Director, Office of Subsidy and Insurance
Maritime Administration
1200 New Jersey Ave, S.E.
Washington, DC 20590
Form MA-528
(Rev. 7-2011)

Application for War Risk Insurance
Appendix A
Vessel Name

Loss Under War Risk Hull and Disbursements Insurance, if any, payable to:

or order
Vessel Name

Loss Under War Risk Protection and Indemnity Insurance, if any, payable to:

or order

Form MA-528
(Rev. 7-2011)

Application for War Risk Insurance
Appendix B

Vessel Name

Form MA-528
(Rev. 7-2011)

Date Built

Category

Mortagee &
Address

Hull

Sum Insured ($)
Disbursements

Protection &
Indemnity

Appendix C
UNITED STATES OF AMERICA
Department of Transportation
MARITIME ADMINISTRATION
CERTIFICATE OF OWNERSHIP AND CONTROL BY UNITED STATES CITIZEN
APPLICANT FOR WAR RISK INSURANCE
I, ______________________________________, __________________________________________
(Name)

(Title)

of ______________________________________, __________ am duly authorized to execute this
(Name of Corporation)

certificate of citizenship to comply with the requirements for obtaining War Risk Insurance to cover the
vessels described in Appendix B_________________________________________________________
___________________________________________________________________________________.
That ____________________________________________ is a _______________________________
(Name of Corporation)

(Country)

corporation owned and controlled by______________________________________________________
___________________________________________________________________________________
(Give sequence of majority ownership and control of all owning or controlling corporations or other
owners, if any, and furnish the full information as to each, if above space is not adequate, continue on
back of this form.)
a corporation organized and existing under the laws of _______________________________________
(Country)

the majority (51% or more) of the stock of which corporation is owned and controlled by citizens of
______________________________________.
(Country)

That of the stock interests shown above to be owned and controlled by __________________________
citizens, none is held beneficially for a citizen of another country.

(Country)

_________________________________
(Signature)

Company Seal

_________________________________
(Typed or printed name of signer)

Dated: __________________________
NOTE: The United States Criminal Code makes it a criminal offense for any person knowingly to make a
false statement or representation to, or to conceal a material fact from, any department or agency of the
United States as to any matter within its jurisdiction (18 U.S.C. 1001 ), or to file a false, fictitious or
fraudulent claim against the United States (18 U.S.C. 287).

Form MA-528
(Rev. 7-2011)

UNITED STATES OF AMERICA
OPTIONAL WAR RISK DISBURSEMENTS
INSURANCE ENDORSEMENT
Attached to and forming part of Interim Binder No. WR-_______________________________
This endorsement insures, as additional coverage, disbursements of the assured on board the
vessel named in the standard form of War Risk Hull Insurance Interim Binder, limited to
consumable and subsistence stores, slop chests, bar stock and bunker fuel in the total amount
of (See Appendix B), against the risks of loss as a consequence of the actual or constructive
total loss of the vessel insured, subject to the terms, conditions and warranties set forth in the
interim binder to which this endorsement is attached.
It is understood this insurance, made available as authorized under section 1203(c), Title XII, of
Merchant Marine Act, 1936, as amended, is additional to the coverage provided in the War Risk
Hull Insurance provision of the standard Interim Binder of Insurance.
Further, it is understood and agreed that in the event of loss, payment of claim shall be limited
to the actual value of the disbursements lost as a consequence of the actual or constructive
total loss of any vessel listed in Appendix B, but said claim shall not exceed the amount of
insurance provided in this endorsement.

Form MA-528
(Rev. 7-2011)

UNITED STATES OF AMERICA
By Maritime Administrator
Acting for the Secretary
of Transportation

_____________________________________________
(Maritime Administrator)
Countersigned at New York, N.Y., this ____________ day of __________________________, 20_____.
AMERICAN WAR RISK AGENCY
By ____________________________________________
(Authorized underwriting agent)

Form MA-528
(Rev. 7-2011)