If the questions do not apply please put NA Named Insured If Corporate, Beneficial Owner Date of Birth Occupation Street Address City, State, Zip Home Number Work Number Cell Number Driver's License Number DL State Your Email Vessel Information Year Built Length Manufacturer/Builder Model Hull ID Number Name of Yacht Registration# Vessel Flag Date Purchased Purchase Price Type Power Multi Hull Sail Houseboat Construction Fiberglass Wood Aluminum Kevlar/Carbon Fiber Steel Other Use Private Pleasure Captain Charter Bare Boat Charter Racing Engine Manufacture/Model Year Built Serial Number(s) Fuel Type Diesel Gas Propulsion Inboard Outboard I/O Pod Drive Jet Drive Engine(s) Single Twin Triple Quad Horsepower(each) Max Speed (MPH) Fuel Tanks Metal F/G Auxiliary Generator Diesel Gas Navigation/Safety Equipment/Security Auto Fire Ext. Fume Detector Radar GPS Depth Finder Auto Pilot Engine Alarm VHF Radi Theft Alarm Tracking Device Surveillance System Locked/fenced Enclosure Secured building Yacht Controller Other Explain: # of Hand Held Fire Extinguishers Current Survey Yes No Date of Survey Afloat Drydock Name of Surveyor Attach Survey Training/Experience Years Boating Experience Boating Courses None U.S. Power Squadron U.S. Coast Guard Auxiliary Mariner's License Describe: Boats Previously Owned Dates Owned Manufacturer Type Size Waters Navigated Other Operators (List) Age Experience Driver's License Number Loss History (if none, state NONE) Details of any previous losses Date Cause Amount Have you ever been convicted of a felony or DUI? No Yes (If yes, describe) Trailer (may be insured separately for an additional premium) Trailer Year, Manufacturer & Model Serial Number No. of Axles Capacity Stored on Trailer Yes No Insurance Coverages Requested Coverage Amount of Insurance Deductible Named Windstorm Deductible Vessel Hull and Machinery $ $ $ Tender & Outboard $ $ Trailer $ $ Liability (P&I) $ $ Medical Payments $ $ Personal Effects $ $ Uninsured Boaters $ $ Crew Liability $ $ Navigation Area East Coast U.S. Florida Bahamas Inland USA Gulf of Mexico Great Lakes Pacific Coastal Caribbean Other Describe: Lay Up Dates From: To: Ashore Afloat Mooring Locations (Marina/Address, City, State, Zip Code) Storage Dock/Slip Trailer Lift Rack Other If Other, please state: Lienholder name & address Loan Number Loan Balance Additional Insured name & address Other Information EXPLAIN ALL "Yes" Responses in Remarks Yes No Remarks Is yacht ever chartered to others with captain? Yes No If yes, is yacht owner operated? Yes No Is yacht ever chartered to others without captain? Yes No Is yacht used commercially or for business purposes? (explain) Yes No Do you employ a paid captain or crew? If so, how many? Yes No Do you live aboard full-time? Yes No Has any carrier canceled or non-renewed coverage? Yes No Is yacht used for racing? Yes No For fare paying passenger vessels, advise the maximum/average # of passengers per trip? Number of trips annually The completion and signing of this application does not bind the APPLICANT or this COMPANY to effect insurance on this risk; it is submitted for purposes of rating and quotation only. If accepted by this COMPANY it is agreed the information furnished herein shall be the basis of the contract should a policy be issued. IT IS UNLAWFUL TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT, FINES, DENIAL OF INSURANCE, AND CIVIL DAMAGES. Applicant Digital Signature Date Current Insurer Policy Effective Date Annual Premium This notice is given in compliance with the Federal Fair Credit Reporting Act (public Law 91-508) and the Consumer Credit Reform Act of 1996. I understand that as part of the insurer's underwriting procedure, a routine credit report may be obtained, as well as a motor vehicle record report. THIS COVERAGE IS A NAMED OPERATOR POLICY. ONLY PRE-APPROVED PERSONS MAY OPERATE VESSEL. THIS COVERAGE EXCLUDES RACING, RACING TRIALS, OR CONTESTS. 2+3=?
