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Application Form
Assured Full Name
*
Phone
*
Email
*
Effective Date
Month
Month
Day
Year
Mailing Address
VESSEL INFORMATION
Vessel Name
Year
Length
Manufacturer/ Model
Max Speed
Purchase Price
Present value
ENGINE DETAILS
Number of Engines
Year
HP
Manufacturer
COVERAGE LIMITS
Hull Physical Damage (USD) -
Tender/ Dinghy (USD)
Third Party Liability (USD)
Liability to Paid Crew (USD)
Liability to Charter Passengers (USD)
Personal Property (USD)
Medical Payments (USD)
Uninsured Boaters (USD)
Trailer (USD)
NAVIGATION DETAILS
Waters to be navigated in the next 12 months
MOORING INFORMATION
Primary Mooring Location (please provide the vessel mooring location July 1st to November 1st)
LAYUP DETAILS
Layup Location
Layup Start (DD/MM/YY):
Month
Month
Day
Year
Layup End (DD/MM/YY):
Month
Month
Day
Year
Layup Status
Ashore
Afloat
NAMED OPERATOR
Full name
DOB
Month
Month
Day
Year
Violations/ Suspension (including auto) in the last 5 years
Years of boating experience
Previous vessel operated (need make & length)
Years of experience as: Operator, Owner, Charter & Boating Qualifications
Length/ Make of Previous Vessels
GENERAL INFORMATION
Is this vessel chartered to others with a captain?
Yes
No
If yes, confirm max passengers per trip.
Does this applicant employ paid crew? If yes, how many?
Is this vessel chartered to other without a captain, on a bareboat charter basis?
Yes
No
Is the vessel used for any other commercial or business purposes? If yes, please explain:
Will this vessel be operated singled handedly?
Yes
No
Will this vessel participate in any races, regattas, or rallies?
Yes
No
Does anyone reside aboard the vessel (liveaboard) during the policy period?
Yes
No
Was any insurance declined, cancelled or non-renewed in the last 5 years? If yes, please explain:
Have you or any named operator been involved in a loss in the last 10 years (insured or not)?If yes, please explain:
Have you or any named operator been convicted of a criminal offense or pleaded no contest? If yes, please provide full details:
Remarks
Submit
First name
*
Last name
*
Email
*
Phone
*
Address
How can we help?
Submit
Get
in Touch
HOME
ABOUT US
SERVICES
Pleasure Boating
Captain Charter Insurance
Bareboat Charter Insurance
Business Use Marine Insurance
Worldwide Navigation Insurance
Liveaboard Insurance
CONTACT US
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