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(property rented to others)
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Client Info

Name    Address

City    State     Zip

Daytime phone     Best time to call    AM    PM 

eMail

Occupation     For how long?

Current Yacht Insurance Info

Company name     Policy expiration

Premium amount $    Term

Coverages

TYPE SUMS INSURED TYPE SUMS INSURED
Hull - Physical damage $
Tender/Dingy $
Liability Coverage $
Crew Liability $
Owner/Operator M & C $
Medical Payments $
Commercial passenger $
Uninsured Boater $
Trailer $
Personal Property $
Non-emergency towing $
Other $

Vessel Info

Vessel name     Manufacturer

Year     Length     Date of purchase     Model

Purchase price $     Present value     Max speed

Registration #    Hull ID#

Waters to be navigated

Tenders     Dingies     Stored on trailer     Will be trailered over 100 miles

Storage address     City     State

Zip

Laid up from to     On-shore     Afloat

Will vessel be located between 12o 40' - 23.5o N and 55o - 87o W during the period July 1st through November 1?

Vessel Equipment

Please select all equipment on your boat/watercraft

Bilge pump
Fume detector
Other (listed below)
EPIRB
Fire extinguisher
Sonar
Cooking stove
Depth sounder
Engine alarm
LORAN/Direction Finder
Anti-theft devices
GPS
Life raft
Radar
Ship-to-shore radio
SATNAV/OMEGA
Aux generator, diesel
CO2/Halon
Aux generator, gas

Additional Vessel Info

Check all that apply

PRIMARY POWER TYPE OF HULL HULL MATEIAL
FUEL TANK
Sail Sailboat Wood
Metal
Outboard Performance Metal
Fiberglass
Inboard Runabout Fiberglass
Plastic
Inboard/Outdrive Pontoon  
Other    

Engine Info

Please complete for each engine

ENGINE 1

Horsepower     Gas     Diesel     Year     Purchase date

Purchase price $     Present value $

Manufacturer     Model

 

ENGINE 2

Horsepower     Gas     Diesel     Year     Purchase date

Purchase price $     Present value $

Manufacturer     Model

 

ENGINE 3

Horsepower     Gas     Diesel     Year     Purchase date

Purchase price $     Present value $

Manufacturer     Model

Trailer Info

Year     Date purchased    Purchase price $     Present value $

Manufacturer     Model     Serial #

Operator

Always list insured as Operator 1

OPERATOR 1

Name     Date of birth     Auto D.L#

State     SS#     Years boat ownership

Auto violations/suspension in past 5 years

USCG/Power Squadron certificate

 

OPERATOR 2

Name     Date of birth     Auto D.L#

State     SS#     Years boat ownership

Auto violations/suspension in past 5 years

USCG/Power Squadron certificate

 

OPERATOR 2

Name     Date of birth     Auto D.L#

State     SS#     Years boat ownership

Auto violations/suspension in past 5 years

USCG/Power Squadron certificate

Yacht Usage

Explain all yes responses in remarks

1. Is the boat chartered to others with captain?

YES NO

2. Is the boat chartered to others without captain?

3. Is the boat used for racing?

4. Is the boat used for water skiing or diving?

5. Is the boat used commercially or for business purposes?

6. Does the applicant emply a paid crew? (If yes, how many?)

7. Any operator involved in a marine loss in the last 10 years? (Insured or not)

8. Any coverage denied, cancelled or not renewed during the past 5 years?

9. If used for fare paying passenger charters, what's the avg. passengers per trip?

10. If used for fare paying passenger charters, what's the avg. passengers per year?

Remarks

   

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