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Home Forms Owner’s / Skipper’s Questionnaire

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

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