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---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

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Actual Sailing Grade*

---PilotMasterTug CaptainTug MateOperatorChief Mate2nd/3rd MateChief EngineerAsst. EngineerTankerman

Employer

Previous Incidents*

YesNo

Explain Previous Incidents (If Yes)

License Defense Costs

---Unlimited100.000500.000

Loss of Income

Civil Legal Defense

---$100,000$250,000$500,000$1,000,000

Civil Penalty Defense

---$10,000$50,000$100,000

Civil Liability

---$50,000$100,000$250,000$500,000$1,000,000

Criminal Acts Defense

YesNo

Fines and Penalties

---$25,000$50,000$100,000$500,000$1,000,000

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