Owner’s / Skipper’s Questionnaire

To be completed by the skipper as a supplement to the Marine Insurance application.

Name of owner / skipper*
First Last
Date of Birth*
MM slash DD slash YYYY
Email*
Phone*
Address
Street Address City State / Province / Region ZIP / Postal Code Country
How long have you been fishing?*
Certificates / Qualifications held*
Please upload any certificates/qualifications/licenses held
Drop files here or

Max. file size: 50 MB.
Details of previous vessels owned / skippered / crewed on in the last 5 years:*
Vessel Home Port Size of Vessel Position Held Dates
Claims / Loss record of skipper for the last 5 years on all vessels operated, whether insured or not
Year Date of Loss Amount Involved Insurer Amount of Claim
Have you at any time been involved in any major damages / total losses on any vessel whether insured or not?
Give brief details including date, costs, and name(s) of vessel(s) involved*
I hereby declare that the particulars and answers given in this questionnaire are in every respect true and correct and that I have not withheld any information which could influence the decision of the company in regard to it’s acceptance.
Signature*
Date*
MM slash DD slash YYYY
Failure to disclose all relevant facts by the assured may invalidate the policy.
Email
This field is for validation purposes and should be left unchanged.

Vessel	Home Port	Size of Vessel	Position Held	Dates

Year	Date of Loss	Amount Involved	Insurer	Amount of Claim