Chubb Marine Insurance Application

Marine Insurance Application

Requested Coverage Type: Masterpiece Boat Masterpiece Boat Select Masterpiece Yacht Masterpiece Yacht Select

Insured Information

Policy to be issued in the name of:
Name of beneficial owner (if different) / additional owner

Residence address

Residence address

City
State
ZIP
City
State
ZIP

Country/Province
Country/Province

Owner / Operator Information

Primary owner's SSN
Primary owner's email
Primary owner's marital status
Primary owner's home ownership/residence status

Primary owner's phone number
Primary owner / beneficial owner's occupation
Primary owner / beneficial owner's employer or name of owned business

Does primary operator hold a USCG license? Yes No   Is there a paid captain? Yes No   Does captain hold a USCG license? Yes No   Total # of paid crew (incl. captain)

Regular operator name(s)

D/O/B
Driver license # / state
Boating courses
Yes No # yrs boats owned

Previously owned vessels (length / make / model)

Loss & Insurance History

Does primary owner(s) currently have insurance for this vessel? Yes No

Previous / current insurance company name and premium:

Has owner ever had insurance cancelled, non-renewed or declined? Yes No

If yes, give company name(s), date(s) and reason(s):

Has any owner or operator sustained any marine claims or losses? Yes No

If yes, provide company names, date(s) of loss/claim, cause and amount paid:

Does vessel have unrepaired damage or was it purchased as salvage? Yes No

If yes provide details:

Vessel & Equipment Information

Year built
Length (feet)
Builder/manufacturer
Model name
Vessel type

Purchase price
Purchase date
Hull ID / documentation #
Vessel's name
Maximum speed (mph)

Hull material
Last marine survey date
Mast material (if sailboat)

Engine/propulsion drive system
# of engines
Total H.P./CC’s
Fuel type

Engine manufacturer
Yr built
H.P. each
Engine serial numbers (outboard only)

Equipment (check all that apply)

Built-in Auto Fire Extinguishing System Fume Detector Carbon Monoxide Detector Alarm/Monitoring System

Trailer manufacturer
Year built
Purchase date
Trailer value
Trailer serial number

Ownership/Operation of Vessel

Waters to be navigated

Lay up period from (mm/dd)
To (mm/dd)
If laid up, vessel is decommissioned

Berth/mooring location of vessel (June - November)
Marina name

Mooring address

Mooring city

Mooring zip code

Mooring state

Country
Berth/mooring type from June - November (check one)
Afloat @ Dock/Slip
Afloat @ Mooring
On Hydraulic Lift
On Trailer
Rack Storage (Inside)
Rack Storage (Outside)
On Jack Stands or Stilts
Other

Berth/mooring location of vessel (December - May)
Marina name

Mooring address

Mooring city

Mooring zip code

Mooring state

Country
Berth/mooring type from December - May (check one)
Afloat @ Dock/Slip
Afloat @ Mooring
On Hydraulic Lift
On Trailer
Rack Storage (Inside)
Rack Storage (Outside)
On Jack Stands or Stilts
Other

Vessel is: (check all that apply)

Raced in other than club races Lived aboard on a permanent / semi-permanent basis
Bareboat Chartered days/year Chartered w/ Captain/Crew days/year, with passengers (max)
Used for other commercial purposes Owned by more than two individuals/entities

Insurance Coverage Requested

Effective date of coverage

Property damage coverage limit
Deductible
Supplemental coverage limit
Deductible

Liability coverage (incl. pollution) limit
Medical payments limit
Uninsured boater limit
L&HCA statutory limits

Trailer limit
Trailer deductible
Personal property limit
Personal property deductible

Emergency towing & service limit
Tender/dinghy limit
Tender/dinghy deductible
Paid crew limit

Special Conditions / Other Coverages

Loss Payee / Additional Insured Information

Acknowledgements

Important Notice Regarding The Fair Credit Reporting Act: Personal information about you, including information from a credit or other investigative consumer report may be collected from persons other than you in connection with this application for insurance and subsequent amendments and renewals. This information will be used solely by the underwriting insurance company(s). Credit-based insurance scoring information may be used to help determine either your eligibility for insurance or the premium you will be charged. At your request, we will provide you with the sources of these reports, their addresses and customer service phone numbers for verification and correction of your information.

Fraud Statement: Any person who knowingly and with intent to defraud any insurance company or another person files an application for insurance containing any materially false information, or conceals for the purposes of misleading, information concerning a fact material thereto, commits a fraudulent insurance act, which is a crime and subjects the person to criminal and civil penalties.

Owner's Statement: I certify that to the best of my knowledge all statements on this application are true, complete and correct and that the information is being offered to the company as an inducement to issue the policy for which I am applying.

Producer's Statement: My (the agent/producer) signature verifies that all of the information on this application has been obtained by me from the applicant and that I have no reason and no basis to believe that the information is anything but truthful.

Agency name
Producer code