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 Number of Motors Hull ID Number Name of Yacht Registration# Vessel Flag Date Purchased Purchase Price Type PowerMulti HullSailHouseboat Construction FiberglassWoodAluminumKevlar/Carbon FiberSteelOther Use Private PleasureCaptain CharterBare Boat CharterRacing Engine Manufacture/Model Year Built Serial Number(s) Fuel Type DieselGas Propulsion InboardOutboardI/OPod DriveJet Drive Engine(s) SingleTwinTripleQuad Horsepower(each) Max Speed (MPH) Fuel Tanks MetalF/G Auxiliary Generator DieselGas Navigation/Safety Equipment/Security Auto Fire Ext.Fume DetectorRadarGPSDepth FinderAuto PilotEngine AlarmVHF RadiTheft AlarmTracking DeviceSurveillance SystemLocked/fenced EnclosureSecured buildingYacht ControllerOther Explain: # of Hand Held Fire Extinguishers Current Survey YesNo Date of Survey AfloatDrydock Name of Surveyor *** Please email survey directly to Jason@insurethisboat.com *** Training/Experience Years Boating Experience Boating Courses NoneU.S. Power SquadronU.S. Coast Guard AuxiliaryMariner's License Describe: Boats Previously Owned Dates Owned Manufacturer Type Size Waters Navigated Year of Boat Model of Boat Top Speed Other Operators Other Operators (List) Age Experience Driver's License Number Date of Birth Other Boats Operated Dates Owned Manufacturer Type Size Waters Navigated Year of Boat Model of Boat Top Speed Loss History (if none, state NONE) Details of any previous losses Date Cause Amount Have you ever been convicted of a felony or DUI? NoYes (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 YesNo Trailer Value 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.FloridaBahamasInland USAGulf of MexicoGreat LakesPacific CoastalCaribbeanOther Describe: Lay Up Dates From: To: AshoreAfloat Mooring Locations (Marina/Address, City, State, Zip Code) Storage Dock/SlipTrailerLiftRackOther 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? YesNo If yes, is yacht owner operated? YesNo Is yacht ever chartered to others without captain? YesNo Is yacht used commercially or for business purposes? (explain) YesNo Do you employ a paid captain or crew? If so, how many? YesNo Do you live aboard full-time? YesNo Has any carrier canceled or non-renewed coverage? YesNo Is yacht used for racing? YesNo 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+7=?
