YACHT INSURANCE APPLICATION

Applicant's Name:
Mailing Address:
City    State    Zip
Phone:      Fax:

PROPOSED EFFECTIVE DATE:
From     To
12:01 A.M. Standard Time at the address of the Applicant
Email Address:

Occupation:
If insured is not owner of the vessel, please indicate name and address of owner
Name:      Address:

OPERATOR INFORMATION   (All anticipated operators must be listed)
Name
Date of Birth
Drivers License #
State
Years of Boating Experience

Driving Record (past 3 years) 
Prior Carrier:     Premium:  $    Exp. Date: 

Description of Prior Owned Vessels:
 
Loss History for past 5 years in detail (if none, state none):


 Has any policy or coverage been declined, cancelled or non-renewed? Yes   No
If “Yes”, please explain.   
 BOAT INFORMATION
 Year:     Make:     Model:     Length:   
 “Name”:    Reg.# / Hull ID#     
 Boat Type: Inboard    Outboard    I/O    Sailboat    Houseboat   Other
 Boat Construction Fiberglass    Wood    Metal
 MOTOR INFORMATION
 Year:     Make: HP Serial Number
 Fuel: Gas Diesel      Maximum Speed:

 Please complete if Maximum Speed is 45 mph or higher
 Outdrives – Make/Type    Serial Numbers
 Drive Lock / Anti-theft device Yes No
 EQUIPMENT
     CB Radar Ship-Shore Radio Auto CO2 or Halon System - Date Certified
     VHF Loran Satellite Navigation Depth Sounder Single Side Band
 Additional Equipment:

 TENDER INFORMATION
 Year:     Make:      Length    Serial Number
 Engine:    Year      HP Serial Number


 TRAILER INFORMATION
 Year:     Make:     Serial Number

 LIENHOLDER INFORMATION
 Lienholder Name      Account #
 Address     City    State    Zip

 NAVIGATIONAL LIMITS

Inland waters of the state(s) of
Inland and coastal waters of the state(s) of
Inland and coastal waters of Florida only.
Inland and coastal waters of Florida and the Bahamas.
Inland and coastal waters from Brownsville, TX to Key West, FL.
Inland and coastal waters from Norfolk, Virginia to Fernandina Beach, Florida.
Other

 INTENDED MOORINGS
 Marina Name
 Address     City    State    Zip
 LAY-UP / STORAGE
 Marina Name
 Address     City    State    Zip

 Vessel Usage – Private Pleasure Only

 INSURANCE
 Property Insurance:  Yacht $     Tender $     Trailer $
 Deductible $ Medical Payments $    Liability Insurance Limits $
 Uninsured or Underinsured Boater $     Water Skiing Liability $
 Excess Liability Limits (Not part of the Primary Limit)$      Personal Effects $

 

 Application Completed By:     Date: