Have a Question About Your Insurance Interests?

* Required

Application Contact Information

Prefix:

* First Name:

* Surname:

* Address 1:

Address 2:

* City:

* State / Province:

* Zip / Postal Code:

* Country:

* Citizenship:

* Country of Residence:

* Telephone:

Fax Number:

* E-mail:

* Occupation:

* Date of Birth:

* Experience in Vessel Operations:

* Describe your area of Navigation:

Vessel Information

* Purchase Price :

$

* Purchase Date:

* Vessel Name:

* Flag:

* Registration Number:

* Vessel Make:

* Vessel Type:

* Vessel Model:

* Vessel Construction:

* Vessel Length:

* Vessel Age or Year Build:

* Engine Type (in/outboard):

* Engine Make:

* Engine Horsepower:

* Maximum Speed:

* Engine, Year Built:

* Months in Commission (not Moored):

* Place of Mooring:

country
city
dock

* Cruising Range:

* Use of Vessel:

* Does anybody live aboard?

Yes No

Check all that apply:

VHF Radio
GPS
Radar
Bilge Alarm
Fume Alarm
Depth Finder
Auto Pilot
Anti-Theft Devices
Auto Fire Extinguishers
Other
Explain:

* List Active Risks:

Survey Information

* Last Survey Date:

* In or Out of Water?

In Out

* Surveyor's Name:

* Surveyor's Address:

* Date of Last Haul Out:

* Major Maintenance :

* Market Value:

$

* Replacement Value:

$

Requested & Current Insurance

* Hull, Machinery and Equipment:

$

* Liability Coverage:

$

* Outboard Engine:

$

* Tender / Life raft :

$

* Personal Effects:

$

* Trailer:

$

* Current Insurer:

* Policy Expires:

* Policy Premium:

$

* Has your coverage ever been revoked, cancelled or not renewed by the insurance carrier?

Yes No
If yes, please explain:

* Boating losses in last 5 years?

Crew Information

Total Crew:

Full Time:

Part Time:

Liability:

$

Medical Insurance:

$

Life Insurance:

$

Disability Insurance:

$

Countries Visited

Questions

* Does anyone else have a financial interest in the vessel(s)?

Yes No
If yes, then explain:

* Do you charter out this vessel ?

Yes No
If yes, then explain the type of activity and frequency:

* Is the vessel(s) pledged property?

Yes No

* Do you have a valid drivers license?

Yes No

* What state/province & country?

If no, then explain: