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 *

Driver's License Number

Years of Boat Ownership *

Current Carrier

Current Premium

Is there a loss history? *

Yes

-

Date *

Type of Loss *

Amount *

Add Remove

Previously or current owned vessels:

Make

Model

Length

Add Remove

Loss Payee Information:

Name

Address

City

State

Zip

Type

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

Insurance Coverage Requested:

Property Damage *

Deductible *

Protection & Indemnity (P&I) *

Medical Payments *

Uninsured Boater *

Yes

Towing and Assistance *

Yes

Personal Effects

Trailer

Fine Arts Coverage

Unscheduled Personal Property

Tenders/ Dinghy

Requested Hull & Machinery Deductible Option(s)

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