Application for Yacht Insurance€¦ · If yes and different from above, please provide dates, description & amounts: YACHT TO BE INSURED Year: Length: Manufacturer: Model: Type:

INSURED’S OWNERSHIP EXPERIENCE

Total years ownership: Length & Manufacturer:

USCG: USPS: Captain’s License:

LOSS INFORMATION:

Does the insured have any previous loss history: Yes No

If yes, please provide dates, description & amounts:

Does this yacht have any previous loss history: Yes No

If yes and different from above, please provide dates, description & amounts:

YACHT TO BE INSURED

Year: Length: Manufacturer: Model:

Type: Hull # : USCG Document #: Purchase Amount:

Vessel Name: Hull Material: Mast Material:

Engine Mfr: Engine Model: Number of Engines: Horsepower:

Propulsion System: Max Speed: Fuel Type:

Satellite-based, Theft Deterrent GPS w/Tracking Capability*:

Yes No

Make: Model:

*(If GPS system is required by Insurance Company, it must be activated and in service 24/7)

Has a survey been performed or scheduled: Survey Date:

Surveyor: Market Value: Replacement Cost:

Name of Current/Previous Insurance Carrier:

Has your insurance ever been non-renewed or cancelled :

Yes No

If yes, please provide details:

COVERAGE AND AMOUNTS:

Purchase Price: $ Insured Value: $ Hull Deductible: $

Theft of Yacht Deductible: $ Wind Deductible: $ Liability Limit: $

Medical Payments: $ Uninsured Boaters: $ Personal Effects: $

Towing: $ Request for War: Yes No

YACHT APPLICATIONDate: Agency:

Purchase Date: Effective Date of Coverage:

Titled Owner of Vessel:

Address:

City: State: Zip:

Beneficial Owner's Name(s):

Date of Birth(s):

Occupation(s):

If Florida, does Insured reside there 12 months of the year? Yes No

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TENDERS (must be carried on board and used only to service the yacht)

#1 Year: Length: Manufacturer: Total Value:

Engine Mfr: Year: Horsepower: Propulsion System:

#2 Year: Length: Manufacturer: Total Value:

Engine Mfr: Year: Horsepower: Propulsion System:

#3 Year: Length: Manufacturer: Total Value:

Engine Mfr: Year: Horsepower: Propulsion System:

TRAILER

Year: Manufacturer: Serial #: Value:$:

PERSONAL WATERCRAFT

#1 Year: Manufacturer: Model: Value: $

# 2 Year: Manufacturer: Model: Value: $

# 3 Year: Manufacturer: Model: Value: $

ADDITIONAL WATERCRAFT

#1 Year: Length: Manufacturer: Model:

Hull #: Engine Mfr: Year: Number of Engines:

Total Horsepower: Propulsion System: Total Value: $ Hull Deductible: $

P&I Sublimit: $ Theft of Watercraft Deductible: $ Wind Deductible: $

Towed behind the yacht: Yes No If yes, date of most recent tow/bridle survey:

#2 Year: Length: Manufacturer: Model:

Hull #: Engine Mfr: Year: Number of Engines:

Total Horsepower: Propulsion System: Total Value: $ Hull Deductible: $

P&I Sublimit: $ Theft of Watercraft: Wind Deductible: $

Towed behind the yacht: Yes No If yes, date of most recent tow/bridle survey:

#3 Year: Length: Manufacturer: Model:

Hull #: Engine Mfr: Year: Number of Engines:

Horsepower: Propulsion System: Total Value: $ Hull Deductible: $

P&I Sublimit: $ Theft of Watercraft Deductible:$ Wind Deductible: $

Towed behind the yacht: Yes No If yes, date of most recent tow/bridle survey:

NAVIGATION

Requested Areas of Navigation:

MOORING LOCATIONS

Summer / Name: Address:

City: State: Zip:

Country:

Winter / Name: Address:

City: State: Zip:

Country:

Lay-up: Decommissioned and unavailable for use: Yes No Date From: To:

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PRIVATE PLEASURE / CHARTER USAGE:

Usage: (Private Pleasure / Charter) Charter? Number of charters per year: If day charters, number of charter days:

Number of Passengers: Max. Number of Passengers Permitted by Certificate of Insurance:

Average Persons Carried: Type of Charter: Duration of Trips:

Overnight Trips: Yes No Is Food Prepared on Board: Yes No Is Alcohol Served: Yes No

Is this yacht part of a Lease, Timeshare, Fraction Share, Vacation Club or similar type arrangement? Yes No

CREW INFORMATION

Paid Captain: Captain’s Name:

Captain’s Experience:

Captain’s Loss History:

Alternate / Relief Captain’s Info:

Number of Full-time crew (not including captain): Number of part-time crew:

LOSS PAYEE / BANK / LEINHOLDER:

Name: Address:

City: State: Zip:

Breach of Warranty required: Yes No If so, amount of loan:

Name: Address:

City: State: Zip:

Breach of Warranty required: Yes No If so, amount of loan:

ADDITIONAL INSURED

Name: Address:

City: State: Zip:

Name: Address:

City:

State: Zip:

I declare that the answers above are true to the best of my knowledge and that all material facts related to the risk to be insured have been disclosed. I also agree that

the information given herein shall form the basis upon which the insurance will be offered, as well as the basis for the insurance contract between me and the insurer if a

policy is subsequently issued. Non disclosure or misrepresentation of any material fact related to the risk may result in the withdrawal of the offer and / or the

nullification of the insurance policy.

Insured’s signature: Date:

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