Fields marked with an asterisk (*) are required.
YACHT APPLICATION
Today's Date:
PRODUCER INFORMATION
Agency Name*
 Current Insurance Carrier
Contact Name*
 Email Address*
Phone Number*
 Policy Effective Date
INSURED INFORMATION
Beneficial Insured Name1*
 Beneficial Insured Name2
Corporate Insured Name
  
Address1*
  
Address2
City*
 State*
 Zip*
Date of Birth
 Occupation
Total Years of Experience*
  
Please list the prior owned vessels by length, manufacturer, and number of years owned*
Loss History (please write none if there have been no losses)*
Has insurance ever been declined, cancelled or non-renewed?
Yes   No
If you answered Yes to this question, please describe below:
Have you taken courses in either of the following?
USCG
USPS 		Does the INSURED have a captain's license? Yes   No
Please specify the type of license held.
YACHT INFORMATION
Year Built*
 Length*
Manufacturer Name*
 Type*
Yacht Name
  
Purchase Date
 Purchase Amount
Hull Construction Material*
 Engine Manufacturer*
Number of Engines*
 Total HP*
Fuel*
 Maximum Speed
Please indicate what equipment is on your yacht:
Compass Fume Detector
Depth Finder VHF
Loran EPIRB
Radar Halon
TENDER INFORMATION
Year Built
 Manufacturer
 Length
 Value
OUTBOARD INFORMATION
Year Built
 Manufacturer
 HP
 Value
PERSONAL WATERCRAFT INFORMATION
Year Built
 Manufacturer
 Value
Year Built
 Manufacturer
 Value
ADDITIONAL VESSEL INFORMATION
Year Built
 Manufacturer
 Length
 Engine Manufacturer
Number of Engines
 HP
 Value
 Is this vessel towed?
Yes   No
COVERAGE INFORMATION
Insured Value Request*
 Hull Deductible Request
 War Coverage Request*
Yes   No
Liability Limits Request*
 Amount of Breach of Warranty (if any)
NAVIGATION REQUESTS
Navigation Limits*
Is there a Lay Up Period?*
Yes   No		  
If so, please indicate the dates
From		  
To
Boating Use*
  
Summer Mooring Location*
 Winter Mooring Location*
CHARTER COVERAGE
For Full Time Charter Vessels ONLY. Please answer the following:
Please describe the type of charter requested (i.e.. Fishing, Pleasure, etc)
Owner's Experience Running a Charter Operation:
 Are the Charters Owner Operated?  
Yes    No
Where are charters run out of?
Summer Location Winter Location
Max # of Passengers
 Avg. # of Passengers
 Any Overnights?
Yes   No
# of Charters Per Day
 # of Charters Per Week
 # of Charters Per Year
Gross Receipts Last Year
 Estimated Gross Receipts This Year
CAPTAIN/ CREW INFORMATION
Captain*
 Captain's Name
Captain's Experience: Type of License held, Vessels Operated (Length/ Manufacturer). Please indicate if the Captain has experienced any losses.
# of Full-time Crew*
(NOT including the Captain) 		# of Part-time Crew*
(NOT including the Captain)
SURVEY INFORMATION
Survey Date
 Surveyor
 Market Value
 Replacement Cost
LOSS PAYEE INFORMATION
Name
 
Address1
  
Address2
City
 State
 Zip
Country
 Phone Number
COMMENTS
Please add any additional comments and/ or any other coverage requests.
PLEASE CLICK TO SUBMIT THIS APPLICATION:

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