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Hull / Protection & Indemnity

  • Date:
    mm/dd/yyyy
  • Name:
  • Address:
  • City:
  • State:
  • Zip code:
  • Occupation:
  • Age:
  • Experience:
  • Size and type of prior vessels owned or operated:
  • List previous losses:

Vessel Information

  • Name:
  • Builder:
  • Year built:
    mm/dd/yyyy
  • Length:
  • Beam:
  • Draft:
  • Displacement:
  • Hull material:
  • Boat type:
  • Doc. number:
  • Hull I.D. number:
  • Engine type:
  • Manufacturer:
  • Year built:
    mm/dd/yyyy
  • Inboard/Outboard or I/O:
  • Horsepower:
  • Single:
  • Twin:
  • Fuel: Gas or diesel:
  • Engine serial number:
  • Date last overhaul:
    mm/dd/yyyy
  • By whom:

List of Equipment

  • Loran: yes no
  • VHF: yes no
  • Radar: yes no
  • Auto pilot: yes no
  • Compass: yes no
  • Direction finder: yes no
  • SSB: yes no
  • CB: yes no
  • Boat type:
  • Depth finder: yes no
  • Built in CO2 or Halon: yes no
  • Fire extinguisher(s): yes no
  • Engine alarm: yes no
  • High water bilge alarm: yes no
  • Generator: yes no
  • Type of generator:
  • Life raft: yes no
  • E.P.I.R.B.: yes no
  • Number of survival suits:
  • Fume detector:
  • Miscellaneous:

Vessel Use

  • Private:
  • Private pleasure:
  • Headboat:
  • Charter:
  • Excursion:
  • Commercial fishing:
  • Other:
  • Number of passengers certified for:
  • Crew coverage:
  • Description of crew:
  • Navigation limits:
  • Principal place of mooring:
  • Is survey available:
    yes no
  • Copy attached:
    yes no
  • Other regular operators:
    yes no
  • If yes (whom):
  • Overnight trips:
    yes no
  • How often:
  • Lay-up:
       From
       To
  • Ashore:
  • Afloat:
  • Current insurer:
  • Ever cancelled or non-renewed:
    yes no
  • Purchase date:
    mm/dd/yyyy
  • Purchase price:
  • Current value:
  • Loss payee:
  • Address:
  • City:
  • State:
  • Zip code:
  • Quote:
  • Coverage bound:
  • Effective date:
    mm/dd/yyyy
  • By whom:
COVERAGE DESIRED AMOUNT DEDUCTIBLE PREMIUM
Hull & Machinery
Prot & Indemnity
Medical Payments
USL&H (incl if P&I cov)
Crew Coverage
Other Coverage
Desired Description 		     
    TOTAL PREMIUM:
Additional Information:

** The above statement, made and accepted by the owner, warrants the information set forth in this application as correct and a true basis upon which insurance may be granted. **

  • Signature of owner: I accept I do not accept
  • Date:
  • Application must be signed (selecting the "I accept" button above constitutes your signiture) by the owner to avoid return.
  • ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR PERSON FILES AN APPLICATION FOR INSURANCE CONTAINING ANY FALSE INFORMATION, OR CONCEALS, FOR THE PURPOSE OF MISLEADING INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME PUNISHABLE BY LAW.