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How did you hear about Us or Find Us? |
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1. GENERAL INFORMATION: |
Owner's Name: |
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Date of Birth: |
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Type: |
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Occupation: |
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If the address is the same, please click here |
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Requested Start Date |
From:
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2. HULL INFORMATION: |
Boat Name:
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Make:
Model:
Year Built:
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Year Last Survey:
Reconstruction Year:
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Max Speed:
Hull Construction Material:
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Boat Type: |
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Boat Size: |
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Hull Serial #:
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Hull Value:
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$
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Use of Boat: |
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Please describe in detail the type of business , include number of crew members,number of weeks that boat will be chartered for ,etc : |
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Date Purchased: |
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Purchase Price : |
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Boating Exprience(Details of length and nature of your boating exprience including qualification and details of previously owned vessels) : |
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Country of Origin:
Port of Registration:
Flag:
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Automated Fire Suppression System
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Number of Crew members:
Number of Passengers:
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Navigation Zone:
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Motors/Engines:
Inboard Motors
Outboard Motors
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H.P. :
Fuel. :
Inboard Motors are considered Part of the Hull Value, Please include Inboard Motors in the Hull Value Above. |
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Extra Passenger Boat: Yes No
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Personal Effects (Fishing Equipment, Electronics, etc.)
Yes No
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Trailer Information:
Yes
No
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Loss History:
Any Claims in the last 3 Years?
YES
NO |
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Choose Number of Additional Watercraft Operators (All Information must be Completed as per Underwriting Requirements)
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FOR ANNUAL POLICIES ONLY : USE OF WATERCRAFT IN MEXICO |
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DESCRIBE SAFETY & CATASTROPHIC CONTINGENCY PLAN (In the Event of a Hurricane or Strong Tropical Storm What Will be Done to Protect your Vessel - Details Are Required) |
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ADDITIONAL COMMENTS |
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Do you employ a captain or caretaker ? |
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Does Insured have a safety & catastrophic contingency plan?
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Location of Watercraft During a Hurricane?
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THIS DOCUMENT REPRESENTS ONLY AN INSURANCE REQUEST, THEREFORE THIS DOES NOT REPRESENT ANY WARRANTY THAT IT WILL BE ACCEPTED BY THE INSURANCE COMPANY OR THAT IN CASE OF ACCEPTATION THIS WILL BE EXACTLY AS REQUESTED. |
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Applicant's Statement
I have read the above application and any attachments. I declare that the information I provided is true, complete and correct to the best of my knowledge & belief. This information is being offered to the company as an inducement to issue the policy for which I am applying and no coverage is offered at this time.
This is only a submission of your informal application. This application does not bind coverage for you or the Insured Item in which you are requesting information about.
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