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Home Forms Application for Marine Insurance

Application for Marine Insurance

If a question does not pertain to your business, please enter N/A

"*" indicates required fields

Producer Information

General agent code:*

Producer code:*

Desired effective date:*

Name*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Contact Email*

Section 1: Business Information

Named insured (including DBA names):*

Tax ID/FEIN #:*

Mooring location zip code:*

Year business was established:*

Location/marina address:*

Street Address City State / Province / Region

Mailing address:*

Street Address City State / Province / Region

Primary Phone:*

Secondary Phone:*

Email*

Website*

Section 2: Designee Information

First Designee Name:*

First Last

Date of Birth*

MM slash DD slash YYYY

Home Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

SSN:*

Second Designee Name:*

First Last

Date of Birth*

MM slash DD slash YYYY

Home Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

SSN:*

Section 3: Business Detail

Usages:*

Bed and Breakfast

Commercial Fish

Boat School

Other/Owner

Describe your operational experience:*

Describe your business in detail:*

Who is your current insurer?*

Has anyone involved with the business ever been convicted of a felony?*

Yes

No

Has the business been cancelled, non-renewed, or refused insurance coverage?*

Yes

No

Additional insured(s):

Please provide name, address, and relationship.

Please list, date, and describe all prior business and marine losses/claims:*

Section 4: Safety

Please explain your safety measures.*

Section 5: Boat Usage

Is the business in compliance with all legal requirements?*

Yes

No

Is overnight usage of the units allowed?*

Yes

No

Is operation permitted from dusk to dawn?*

Yes

No

Are all units seaworthy and fit for their intended purpose?*

Yes

No

Are all units and components unmodified and stock?*

Yes

No

If a pontoon, are all access gates attached and in good working order? Photos required.*

Yes

No

Is seating available for all guests that is permanently affixed and in good condition?*

Yes

No

Do you lay up the unit seasonally?*

Ashore

Afloat

On a lift

If yes, please select one.

If any unit is leased or borrowed, explain the arrangement and provide the contract:*

Lienholder(s)/Loss payee(s):*

Section 6: Naviagtion

Describe the waters where the units are used.*

If coastal:

1 Mile

5 Miles

25 Miles

50 Miles

100 Miles

Section 7: Operator Information

Name Operator*

Please list experience for the three most recent vessels owned or operated.*

Vessel year

Builder

Length

From (mo/yr)

To (mo/yr)

Owned (y/n)

Operated (y/n)

Describe training and safety courses taken:

Has the operator sustained any injuries that required a doctor visit, hospitalization, or professional care in the past five years?

Yes

No

If yes, please describe.

Does the operator have any known health problems?

Yes

No

If yes, please describe.

Does the operator have health insurance?*

Yes

No

Section 8: Charter usage - for charter use endorsement

Does the business owner or a captain operate the vessel more than 75% of the time while under charter?*

Yes

No

Is food or liquor provided to passengers?*

Yes

No

If yes, please describe.*

Unit Schedule

Unit 1*

Bed and Breakfast

Commercial fish

Boat school

Other/owner

For charter use, number of passengers:*

Sail

Mono hull

Multi hull

Fishing

Bass

Center console

Sportfish

Drift boat

Power

Cruiser

Jet boat

Houseboat

Trawler

PWC

Runabout

Airboat

Yacht

Ski boat

Pontoon (photos required)

Commercial boat

Unit Make:*

Year:*

Model:

Serial/Hull ID:

Unit Material:*

Fiberglass

Wood

Steel/metal

Glass over wood

Other

Unit Market Value:*

Number of engines:*

Engine make:*

Year:*

Horsepower:*

Engine Serial:*

Trailer year:*

Trailer make:*

Trailer serial:*

Trailer market value:*

Is unit ever kept on a mooring ball?

Yes

No

If yes, please explain.*

Recent photograph of vessel*

Drop files here or

Max. file size: 50 MB.

Photos of pontoons are required, showing the condition of the unit and that all gates are fully paneled.

Coverage

Named windstorm deductible: In areas where a wind deductible applies, the hull value must be greater than the stated deductible, or 5% of the unit value, whichever is greater.

Owner/Operator	Bed & breakfast, Boat school	Commercial fish
$500	$750	$1,000

Unit deductible

$25,000

$50,000

$100,000

$300,000

$500,000

$1,000,000

No coverage

Personal effects

$1,000

$2,500

$5,000

$7,500

$10,000

$15,000

$20,000

$25,000

Watersport liability

$25,000

$50,000

$100,000

$300,000

$500,000

$1,000,000

No watersport liability

Uninsured boater

$25,000

$50,000

$100,000

$300,000

$500,000

$1,000,000

No uninsured boater coverage

(not available for commercial fish)

Medical payments

$1,000

$2,500

$5,000

$10,000

$15,000

$20,000

$25,000

No medical payments

Pollution liability

$25,000

$300,000

$997,100

No pollution liability

Premise liability?

Premise liability?

Slip and mooring liability?

Additional usage coverage

Boat School*

Yes

No

Captained charter

If yes, No. of passengers?

Bed and breakfast*

Yes

No

Liveaboard

Business interruption

$2,500

$5,000

Captained charter*

Yes

No

If yes, No. of passengers?

Owner/Operator*

Yes

No

Liveaboard

Cargo*

Yes

No

Business Interuption

$2,500

$5,000

Crew liability

$25,000

$50,000

$100,000

$300,000

$500,000

$1,000,000

Applicant Signature*

Producer Signature*

Date*

MM slash DD slash YYYY

Copy of current condition and validation survey*

Max. file size: 50 MB.

Date of Last Survey

MM slash DD slash YYYY

Consent

I agree to the privacy policy.

Name

This field is for validation purposes and should be left unchanged.

Δ

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