Electronics Application

Vessel Name*

Named Assured

Address

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

Email Address*

Phone*

Vessel Details

Year Built

LOA

Gross Tons

Date of Last Vessel Survey

Surveyor

Market Value

Replacement Cost

Vessel Sum Insured

Electronics Details

Electronics Value

Requested Sum Insured

Claims

Please provide details of all Electronics claims within the past 5 years for this and any other vessels owned or operated by you whether insured or not:

Most Recent Survey

Please attach a copy of the most recent survey, including a schedule of the electronics.

Max. file size: 50 MB.

I HEREBY DECLARE THAT THE PARTICULARS AND ANSWERS GIVEN IN THIS APPLICATION ARE IN EVERY RESPECT TRUE AND CORRECT AND THAT I HAVE NOT WITHELD ANY INFORMATION WHICH COULD INFLUENCE THE DECISION OF THE COMPANY IN REGARD TO IT’S ACCEPTANCE.

Signature*

Date

Phone

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

Vessel Details

Electronics Details

Claims

Forms

Our Products

Commercial Fishing Vessels

Charter & Sportfishing Vessels

Yachts

Marine Artisans / Marina Operators

Aviation

Oil Pollution

Nets & Gear

Cargo

Aquaculture

Misc. Coverages

Pin It on Pinterest