Personal Information |
| Applicant Name |
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| Corporate Titled? |
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| Mailing Address |
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| County |
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| Daytime Telephone |
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| Evening Telephone |
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| Email |
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| Requested Effective Date |
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| Previous Insurance Carrier |
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Address Where Boat is Stored in Season |
| This Location is Applicant's |
If other,
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| Vessel is kept on a |
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| Vessel is stored in a |
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Address Where Boat is Laid-Up Off Season |
| Address Where Boat is Laid-Up Off Season |
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| Boat is laid-up between |
to
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| This Location is Applicant's |
If other,
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| Vessel is kept ashore on a |
In a
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| When vessel is not ashore during layup, the vessel is in a |
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Navigation Limits Desired and Range of Navigation |
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US Inland Rivers/Waterways ONLY |
Coastal (up to 25 miles Offshore) |
Atlantic
Pacific
Gulf
Bahamas
Great Lakes/Tributaries
Lakes Mead, Powell, Tahoe |
Extended Navigation Limits
No binding authority is extended: submit for approval with detailed boating experience resume, MVR, and current survey. |
| Offshore Navigation Limit Desired |
|
|
Operator Information (named operator endorsement may apply) |
| Operator 1 |
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Name
Gender
Marital status
Date of birth
Drivers License No.
State
Years Boating
Percent of usage
Occupation
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| Operator 2 |
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Name
Gender
Marital status
Date of birth
Drivers License No.
State
Years Boating
Percent of usage
Occupation
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| Operator 3 |
Name
Gender
Date of Birth
Drivers License No.
State
Years Boating
Percent of usage
Occupation
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Details of convictions, auto accidents, suspensions/revocations, boating accidents and losses |
Date of event
Details
Did accident result in injury or death?
Property Damage Amount
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| |
Boat Usage |
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Pleasure
Commercial
Racing
Primary Residence |
Is this vessel used commercially or leased to others under a barefoot charter contract?
Yes
No
(If 'Yes,' risk is not eligible for this program -- refer to commercial) |
| Is boat used for water skiing, aquaplaning or other water sport?
Yes
No |
How often will boat be trailered to area of use (No. of times a year)?
One-way distance:
miles
Type of vehicle used to tow boat:
|
Previous watercraft owned and operated by applicant (I.E., year, make, length, maximum speed)
|
General Information |
Applicant current employer (if self employed, advise type of business)
Years employed
If less than 2 years, list previous employer
Residence is
Owned
Rented |
Property Description |
| Vessel |
Vessel
Vessel Year
Manufacturer and Model
Hull ID/Serial No.
Fuel type
|
Vessel Purchase Date
Vessel Purchase Price
Current Value
|
| Engine No. 1 |
Engine Year
Manufacturer and Model
Serial No.
|
Engine Purchase Date
Purchase Price
Current Value
|
| Engine No. 2 |
Engine Year
Manufacturer and Model
Serial No.
|
Engine Purchase Date
Purchase Price
Current Value
|
| Engine No. 3 |
Engine Year
Manufacturer and Model
Serial No.
|
Engine Purchase Date
Purchase Price
Current Value
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| Equipment |
| Itemize equipment that is generally required to be onboard for the safe operation, navigation or maintenance of the watercraft. These items must be included in the total watercraft and equipment value or coverage will not be provided
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| Total Value: Vessel, engines, tender and equipment ($25,000 minimum value)
|
| Trailer |
Year
Manufacturer and Model
Serial No.
Current Value
|
| Personal Effects |
| List items that belong to you such as waterskis, fishing gear, cameras, scuba equipment, portable radios, wearing apparel, etc., for which you desire coverage. Misc. items may be covered up to a total amount of $500 if so requested. This coverage is not automatic
|
| Boat Type
Boat Power Type
If other
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| Hull Type
If other
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| Hull Material
If other
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| Safety/Anti-Theft Equipment |
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Marine Compass
Depth Finder
VHF Radio
Loran, Sat Nav or GPS
Radar |
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EPIRB
Electronic Burglar Alarm
Outboard/Outdrive Locks
Propeller Hub Locks |
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Trailer Ball/Axle Locks
Vapor Detection System
Smoke Detectors |
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Auto Fire Extinguisher in Engine Space |
Have the vessel, engine(s) or operating equipment been modified or altered from their original stock condition?
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Have any operators completed a boating safety course (if so, please submit copy of certificates to receive credit)
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During the past three years, have any of the operators had their drivers licenses suspended, revoked or refused, been involved in an automobile accident or been convicted of a moving violation?
If yes, please explain
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Have any of the operators been involved in a boating accident or boating loss during the past five years?
If yes, please explain
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During the past three years, has any operator had any boat or automobile insurance cancelled, been refused issuance or renewal, or received notice of such intent? (MO. residents need not answer)
If yes, please explain
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Is a captain, crew or management service employed to operate or maintain the vessel?
(No crew liability coverage is available)
If yes, please explain
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| Is this vessel currently up for sale?
|
Coverage and Premiums |
| Watercraft and Equipment |
| Limits requested ($)
(ACV applies if hull is under $35,000 and at company option) |
| Hull Deductible |
|
Please specify if other,
% ( Note: 2% is min. for High Performance Ded.) |
Watercraft Liability
(Refer to commercial program for paid captain/crew or for crew liability coverage) |
|
Premium ($)
|
| Medical Payments |
|
Premium ($)
|
| Uninsured Boater |
|
Premium ($15,000 limit) $
|
| Watersports Liability |
|
(Equal to Watercraft Liability, Max. 300,000 CSL) Premium ($)
|
| Slip and Mooring Liability |
|
(Equal to Watercraft Liability, Max. 300,000 CSL) Premium ($)
|
| Personal Effects |
| $
($5,000 maximum. Itemization required for individual items over $500 |
| Trailer Physical Damage |
| $
Premium
|
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| Comments
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