Watercraft Application

Yacht Request

Agent Information

Agency Name *

Agent Name *

E-mail Address *

Insured Information

Name of Insured *

Occupation *

Requested Effective Date: *

Primary Residence Address *

City *

State *

Zip *

Name of Beneficial Owner (If Different) / Additional Owner

Phone Number *

Owner / Operator Information

Name(s) of Regular Operator(s) *

Date of Birth *

Years of Boat Ownership *

Current Carrier *

Current Premium *

Is there any loss history/major violation/auto tickets? *

Yes

-

Date *

Type of Loss/Major Violation/Auto Ticket *

Amount *

Add Remove

Are there other previously or currently owned vessels? *

Yes

Previously or current owned vessels:

Previous Make *

Previous Model *

Previous Length *

Number of years owned *

Which years owned *

Add Remove

Is there a loss payee? *

Yes

Loss Payee Information:

Name *

Address *

City *

State *

Zip *

Crew Information

Is there a paid captain/crew? *

Yes

Captain’s Name *

Captain's Resume *

Drop a file here or click to upload Choose File

Maximum upload size: 8.39MB

Does Captain have a loss history? *

Yes

-

Date *

Type of Loss *

Amount *

Add Remove

Total Number of Paid Crew *

Crew Resume *

Drop a file here or click to upload Choose File

Maximum upload size: 8.39MB

Hull & Machinery Information

Hull & Machinery Value *

Deductible *

Protection & Indemnity (P&I) *

Towing and Assistance *

Yes

Personal Effects

Trailer

Tenders/ Dinghy

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