Sportfishing/Charter Vessel Application

Producer Information

Desired effective date:*

Name*

Phone*

Contact Email*

Copy of current condition and validation survey*

Max. file size: 50 MB.

Date of Last Survey*

Vessels with an Out-of-Water Condition and Valuation Survey of 3 years or older may need to have a new survey performed before coverage can be bound.

Section 1: Business Information

Named insured (including DBA names):*

Tax ID/FEIN #:*

Mooring location zip code:*

Year business was established:*

Primary Phone:*

Secondary Phone:*

Email*

Website

Section 2: Designee Information

Date of Birth*

SSN:*

Date of Birth

SSN:

Section 3: Business Detail

Describe your business in detail:*

Describe your operational experience:*

Who is your current insurer?*

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

If yes, please describe:*

If not, please describe:*

Recent photograph of pontoon gates*

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.

If not, please describe:*

Layup dates, From:

To:

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

Please provide name, address, and relationship.

Section 6: Charter usage

If yes, how many crew (including a hired captain) are on board?

If yes, please describe how alcohol is provided and if there is a charge.*

Describe any shoreside activities.*

Section 7: Bareboat charter usage

How old must a person be to charter a vessel?

How old must a person be to operate?

Describe how you screen and validate the experience of each participant (attach applicable forms).

Section 8: Navigation

Describe the waters where the units are used.*

Section 9: Operator Information

Date of Birth*

Driver's license:*

State

Year USCG licensed:

Describe and provide the month/year for all motor vehicle violations and accidents in the past three years:

Describe and provide the month/year for all marine losses that have occurred personally, or for any vessel when its operator was in control.

If yes, please describe.

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

Vessel year

Builder

From

To

Vessel year

Builder

From

To

Vessel year

Builder

From

To

Describe training and safety courses taken:

If yes, please describe.

Unit Schedule

For charter use, number of passengers:*

Unit Make:*

Year:*

Model:*

Serial/Hull ID:*

Unit Market Value:*

Number of engines:*

Engine make:*

Year:*

Horsepower:*

Engine Serial:*

Trailer year:*

Trailer make:*

Trailer serial:*

Trailer market value:*

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 & Charter-Guide	Captained charter, Bed & breakfast, Boat school	Bareboat charter & Commercial fish
$500	$750	$1,000

Additional usage coverage

# crew

If yes, No. of passengers?

Date*

Comments

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

Producer Information

Section 1: Business Information

Section 2: Designee Information

Section 3: Business Detail

Section 4: Safety

Section 5: Boat Usage

Section 6: Charter usage

Section 7: Bareboat charter usage

Section 8: Navigation

Section 9: Operator Information

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

Unit Schedule

Coverage

Additional usage coverage

Forms

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