PERSONAL WATERCRAFT APPLICATION

Applicant's Name:
Mailing Address:
City    State    Zip
County:

PROPOSED EFFECTIVE DATE:
12:01 A.M. Standard Time at the address of the Applicant
Home Phone:     Work Phone:
Best Time To Call:  
Fax: Email Address:

 CURRENT INSURANCE INFORMATION
  Company Name (not agency):     Policy Expiration Date:
 Premium Amount: $    Term:      If Other:

COVERAGES     Input only for those desired
Type Sums Insured Type Sums Insured
Hull- Physical Damage $ Tender / Dinghy $
Liability Coverage $ Crew Liability $
Owner / Operator M&C $ Medical Payments $
Commercial Passenger Liability $ Uninsured Boater $
Trailer $ Personal Property $
Non-Emergency Towing $ Other $

 VESSEL INFORMATION
 Vessel Name:     Manufacturer/Model:    Year   Length
 Date Purchased    Purchase Price $    Present Value $     Max Speed mph
 Registration #      Hull Identification #:
 Waters to be navigated:    Tenders or Dinghies:
 Storage Address (Street, City, Co., St.):

  LAID UP:     From: to              On Shore      Afloat
  Stored on Trailer: Yes  No        Will be trailered over 100 miles: Yes  No

EQUIPMENT  (please select ALL equipment on your Watercraft)
Bilge Pumps
EPIRB
Sonar
Depth Sounder
LORAN/ Direction Finder
GPS
Radar
SATNAV/ OMEGA
CO2/Halon System 		 Fume Detector
Fire Extinguishers
Cooking Stove
Engine Alarm
Anti-theft Devices
Life Raft
Ship to Shore Radio
Aux Generator, Diesel
Aux Generator, Gas  		   Other (list below)




 

MISCELLANEOUS   Please check ALL that apply
Primary Power
Sail
Outboard
Inboard
Inboard/ Outdrive
Other		 Type of Hull
 Sailboat
Performance
Runabout		 Hull Material
Wood
Metal
Fiberglass		 Fuel Tank
Metal
Fiberglass

ENGINE/OUTBOARD MOTOR INFORMATION   Please complete for each engine
 
H.P.
Fuel
Year
Date
Purchased
Purchase
Price
Present Value
Manufacturer/
Model
Serial Number
Engine 1
Gas
Diesel
Engine 2
Gas
Diesel
Engine 3
Gas
Diesel

 TRAILER INFORMATION
 Year   Manufacturer/Model: Serial Number:
 Date Purchased Purchase Price $ Present Value $

OPERATORS    Always list Insured as Operator 1
 
Name
Date of Birth
Auto DL#
DL State
Social
Security #
USCG/Power Squadron
Certificate #
Years of Boat
Ownership
Operator 1
Operator 2
Operator 3

AUTO VIOLATIONS/SUSPENSIONS      Last 5 years
Operator 1
Operator 2
Operator 3

BOAT/WATERCRAFT USAGE   Explain all "Yes" responses in "Remarks"
Yes
No
Is the boat chartered to others with captain? 
Is the boat chartered to others without captain? 
Is the boat used for racing? 
Is the boat used for water skiing or diving? 
Is the boat used commercially or for business purposes? 
Does the applicant employ a paid crew?   If "yes" how many?
Was any operator involved in a marine loss in the last 10 years (insured or not)? 
Was any coverage declined, cancelled or non-renewed during the last 5 years?
If the boat is used for fare paying passenger charters, what is the average number of passengers per trip?      Number of trips per year?  
Remarks: (explain all "Yes" responses from above)

Please give any additional comments you feel appropriate for this quotation. If you have additional information where there was not enough fields above, please enter them here.

  

 Application Completed By:     Date: