Insureds Name:

Insureds Date of Birth:

Phone Number

E-Mail

Beneficial Owner (required if policy is in a company name):

Address Line 1:

City:

State:

ZIP:

Occupation:

Vessel Name:

Effective dates

from :
to:

If laid up:

Location:

from :
to:

ashore afloat

Hull – Physical Damage:

Tender/Dinghy:

Personal Property:

Trailer:

Medical Payments:

Liability Coverage:

Crew Liability:

Owner Operator M&C:

Commercial Passenger Liability:

Uninsured Boaters:

Breach of Warranty (for loss payee only):

Non-emergency towing:

Other:

Vessel Year:

Vessel length:

Date Purchased:

Purchase Price:

Present Value:

Max. Speed:

Hull ID Number:

Registration Number:

Vessel Flag:

Manufacturer & Model:

Anti-theft Precautions:

Main Mooring/Storage Location (full address):

Tenders or Dinghies:

Waters to be navigated (you may attach an itinerary, please note extended navigation requires supplementary sheet):

Vessel Location July 1st – Nov 1st (including co-ordinates if known):

Bilge Pumps:

Cooking Stove:

Flame Detector:

Co2/Halon System:

Fire Extenguishers:

Anti-theft devices:

Loran/Direction finder:

Depth Sounder:

Radar:

Sonor EPIRB:

GPS:

Engine Alarm:

Generator Diesel or Gas:

Ship to Shore Radio:

SATNAV/Omega:

Life Raft:

Other:

Primary Power:

Sail Outboard Inboard Inboard/Outdrive Other

Type of Vessel:

Sailboat Motor Yacht Sportfisher Cruiser Performance Houseboat

Hull Material:

Fiberglass Steel Aluminum Wood Kevlar Carbon Fibre

Type of Hull (if other, detail):

Monohul Catamaran Other:

Engine 1:

H.P.

Gas Diesel

Year

Date Purchased

Purchase Price

Present Value

Manufacturer

Serial Number

Engine 2:

H.P.

Gas Diesel

Year

Date Purchased

Purchase Price

Present Value

Manufacturer

Serial Number

Engine 3:

H.P.

Gas Diesel

Year

Date Purchased

Purchase Price

Present Value

Manufacturer

Serial Number

Date Vessel Last Surveyed

Ashore/Afloat

Survey been supplied to underwriter:

Yes No

Year

Date Purchased

Purchase Price

Present Value

Manufacturer & Model

Serial Number

Operator Name

Operator Date of Birth

Operator State of Residence

Operator Violations/Suspensions in last 5 years (including Auto)

Boating Qualifications

Years of boat ownership

Years of boating experience

Details of previous vessels owned

Operator Name

Operator Date of Birth

Operator State of Residence

Operator Violations/Suspensions in last 5 years (including Auto)

Boating Qualifications

Years of boat ownership

Years of boating experience

Details of previous vessels owned

Operator Name

Operator Date of Birth

Operator State of Residence

Operator Violations/Suspensions in last 5 years (including Auto)

Boating Qualifications

Years of boat ownership

Years of boating experience

Details of previous vessels owned

Is the boat chartered to others with captain?

Yes No

Is the Boat chartered to others without captain?

Yes No

Will the vessel be used for racing during the policy period?

Yes No

Is the boat used for water skiing or diving whether or not vessel is operated commercially?

Yes No

Is the boat used for fare paying passengers?

Yes No

If yes to fare paying passengers, what is the number of passegers per trip:

Maximum
Average
Number of Trips per year:

Is the boat used commercially or for business purposes?

Commercial Business

Will the vessel be operated single handed at night?

Yes No

Have you or any named operator been involved in a marine loss in the last 10 years (insured or not) ?

Yes No

Was any insurance declined, cancelled or non-renewed in the last 5 years?

Yes No

Does the applicant employ paid crew?

Yes No

If so, how many?

Does anyone reside aboard the vessel?

Yes No

Explanations for questions above that you answered YES to

Is the boat chartered to others with captain?

Please complete supplementary sheet – Captain Charter (link to file on applications.html)

Is the boat chartered to others without captain?

Please complete supplementary sheet – Bareboat Charter (link to file on applications.html)

Will the vessel be used for racing during the policy period?

Please complete supplementary sheet – Racing (link to file on applications.html)

Is the boat used commercially or for business purposes?

Please complete supplementary sheet – Commercial/Business Use (link to file on applications.html)

Does the applicant employ paid crew?

Please complete supplementary sheet – Crew (link to file on applications.html)

Additional information you would like to submit: