Fill and Sign the Commercial Rental Application Form

Commercial Watercraft Rental Insurance Application Requested Effective Date: ___________ General Agent Code: _______ Producer Code: ______________ Producer Name & Address: ________________________________________ _________________________________________  Producer Phone Number: ______ _____ ____________  Fax Number: ______ _____ ____________  Additional Interests: _________________________________________  Relationship To Applicant: ____________________________________ Premium Finance Company: ______________________________________ Address: ________________________________________________________ Applicant Name: __________________________________________________ Mailing Address: __________________________________________________ City: _____________ State: ________________ Zip Code: _______________ Principal Contact: ___________________________ Title: ________________ Physical Address of Operation: (List All Locations including Mooring County and Phone Number of each): ____________________________________________ _______________________________________________________________ _______________________________________________________________ Name and Address of Lienholder: __________________________________ _______________________________________________________________ State How Watercraft is Used for Operation: ________________________ ________________________________________________________________ What Is The Experience Of The Principals With This Type Of Operation? ________________________________________________________________ ________________________________________________________________ Name of Organization: _____________________________________________ [ ] Individual (Sole Proprietorship) [ ] Partnership [ ] Corporation [ ] Limited Liability Company [ ] Joint Venture [ ] Other Operating Period Operating From [ ] Year Round [ ] Marina [ ] Seasonal [ ] Beach Front From ______ to _______ [ ] Public Ramp [ ] Other How Many Years Has Applicant Owned/Operated This Business? _____ How Many Years Has Applicant Operated From This Location? _____ Gross Receipts For This Operation Last Year $________________ Projected Gross Receipts For This Year $________________ List And Describe All Other Commercial Activities Conducted On The Premise, Whether Owned Or Non-Owned: _____________________________________ If Owned, Is There Other Insurance In Force? [ ] No [ ] Yes Explain:____________________________________ ____________________________________ Previous Insurance Carrier: __________________________________________ Expiration Date: ___________ Has Any Company Ever Canceled Or Non-Renewed Insurance For This Applicant? (Missouri residents Need Not Answer) [ ] No [ ] Yes Explain:__________________________________________________________ NAVIGATION LIMITS DESIRED & RANGE OF NAVIGATION [ ] US INLAND RIVERS/WATERWAYS ONLY [ ] COASTAL Up To 25 Miles Offshore [ ] ATLANTIC PACIFIC GULF BAHAMAS [ ] GREAT LAKES & TRIBUTARIES [ ] LAKE MEAD, POWELL OR TAHOE Extended Navigation Limits - NO BINDING AUTHORITY IS EXTENDED Submit for approval with detailed boating experience resume, MVR and current survey. Offshore navigation limit desired: [ ] 25 – 50 MILES OFFSHORE [ ] 50 – 75 [ ] 75 – 100 MOORING LOCATION OF VESSEL WHEN IN USE -- MARINA NAME (IF APPLICABLE), ADDRESS, CITY, STATE, ZIP: ___________________________________ _______________________________________ OPERATING PERIOD: [ ] YEAR ROUND [ ] SEASONAL LAY-UP LOCATION WHEN NOT IN USE -- MARINA NAME (IF APPLICABLE), ADDRESS, CITY, STATE, ZIP: ___________________________________ _______________________________________ TYPE OF LAY-UP: [ ] Ashore [ ] Afloat WHEN NOT IN USE, VESSEL IS: [ ] Ashore [ ] Afloat (NO LAYUP CREDIT ALLOWED IF AFLOAT) WARRANTED ON SHORE LAY-UP PERIOD (MM/DD/YY) FROM: __________ TO: _______________ FIVE YEAR CLAIMS HISTORY - WATERCRAFT & PREMISES Date Of Event: ___________________ Details Of Loss Or Claim: ________________________________________ _____________________________________________ Amount Of Claim: ______________________ Status: _____________________________________________________ Date Of Event: ___________________ Details Of Loss Or Claim: ________________________________________ _____________________________________________ Amount Of Claim: ______________________ Status: _____________________________________________________ How Many Years Has The Applicant Been Doing Business As A Rental Operation? ______________ If A New Venture, List Any Previous Watercraft Rental Experience If Applicable: ______________________________________________________________ ______________________________________________________________ Please Provide All Other Names That This Business Has Operated Under: ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ Who Is Responsible For Overseeing The Watercraft Rental Operations? Name: ___________________________________________________ Title: ______________________________ Date Of Birth: _______________________ Number Of Rental Operation Employees: ________________ Employees and Ages: _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ Are Employees Trained In First Aid, CPR, Etc.? [ ] No [ ] Yes Explain:__________________________________________________________ Describe How Renters Are Screened: __________________________________ ________________________________________________________________ How Old Must A Person Be To Rent The Watercraft? _____________ How Is Renter Age Verified? ________________________________________ What Type Of Instruction Is Provided To Each Renter? ____________________ ________________________________________________________________ Who Provides The Instruction? ___________________________________ Are Renters Allowed To Trailer Units To Other Locations? [ ] No [ ] Yes Explain:__________________________________________________________ Does Insured/Owner Trailer Units To Other Locations? [ ] No [ ] Yes Explain:__________________________________________________________ What Navigation Limits Are Placed On The Renter? (Body Of Water And Range Of Navigation): _________________________________________________ How Is Each Rental Supervised And Assisted If Help Is Required? _____________________________________________________ Is Swimming, Snorkeling, SCUBA Or Diving Allowed From Vessels? [ ] No [ ] Yes Explain:__________________________________________________________ Will Any Person Besides The Contracted Renter Be Allowed To Operate The Vessel? [ ] No [ ] Yes Explain:__________________________________________________________ Are Renters Allowed To Tow Water-Skiers Or Water Toys? [ ] No [ ] Yes Explain:__________________________________________________________ Does Applicant Supply The Tow Rope, Skis Or Water Toys? [ ] No [ ] Yes Explain:__________________________________________________________ Where Are Vessels Kept When Not In Use? _____________________________ How Are Vessels Secured Against Theft? _____________________________ How Long Are Rental Agreements Kept On File? _________________________ Does Applicant Keep Records Of Vessel Maintenance? ____________ Does Applicant Or Any Employee Operate The Watercraft In The Course of Employment? [ ] No [ ] Yes Explain:__________________________________________________________ Does Applicant Or Any Employee Use The Watercraft For Personal Pleasure? [ ] No [ ] Yes Explain:__________________________________________________________ Remarks: _________________________________________________________ To bind coverage the following information must be provided and be deemed acceptable: [ ] A copy of the current Rental Agreement. [ ] A copy of Check out or Renter training procedures. [ ] A complete schedule of all vessels including the lengths of all vessels as well as the serial numbers for each vessel, motor and trailer. [ ] If requesting $1million liability limits, please supply 3-5 years of loss runs NOTE: Coverage will not be bound without an acceptable rental agreement, checkout procedures and a complete vessel schedule on file. COVERAGES AND PREMIUMS WATERCRAFT AND EQUIPMENT (Total of Hull Values from Schedule)  COVERAGE: __________________________________________________  LIMITS REQUESTED: __________________________________________  DEDUCTIBLE: ( Minimum $1000 Deductible) ________________________  PREMIUM: ______________________________________________ WATERCRAFT LIABILITY  COVERAGE: __________________________________________________  LIMITS REQUESTED: __________________________________________  DEDUCTIBLE: ( $1000 Deductible) ________________________  PREMIUM: ______________________________________________ WATERSPORTS LIABILITY  COVERAGE: __________________________________________________  LIMITS REQUESTED: __________________________________________  DEDUCTIBLE: ________________________  PREMIUM: ______________________________________________ PREMISES LIABILITY (SUBMIT PREMISES APP.)  COVERAGE: __________________________________________________  LIMITS REQUESTED: __________________________________________  DEDUCTIBLE: ________________________  PREMIUM: ______________________________________________ TRAILER PHYSICAL DAMAGE  COVERAGE: __________________________________________________  LIMITS REQUESTED: __________________________________________  DEDUCTIBLE: $25.00  PREMIUM: ______________________________________________ PAYMENT OPTIONS [ ] TOTAL ANNUAL PREMIUM ($5 FEE PER INSTALLMENT) ________________ [ ] 3 PAY PLAN (40% DOWN, 30% DUE IN 60 DAYS, 30% DUE IN 150 DAYS. WRITTEN PREMIUM MUST BE GREATER THAN $750). [ ] 6 PAY PLAN (35% DOWN, 15% DUE IN 60, 90, 120, AND 10% DUE IN 150 AND 180 DAYS). WRITTEN PREMIUM MUST BE GREATER THAN $1,500 $1,000 MINIMUM EARNED PREMIUM $1,000 MINIMUM WRITTEN PREMIUM $1,000 MINIMUM DEDUCTIBLE APPLICANT’S STATEMENT AND SIGNATURE This notice is given in compliance with the Federal Fair Credit Reporting Act (Public Law 91-508) and the Consumer Credit Reform Act of 1996. I understand that as part of the Company’s underwriting procedure, a routine inquiry may be made which will provide applicable information concerning character, general reputation, personal characteristics, mode of living and driving record. Upon written request, additional information as to the scope of the report, if one is made, will be provided. I have read this application and the entries on it. I understand that if my watercraft is used in any official or pre-arranged race, contest or event or is being held for sale, that this type of usage will void the obligation of the Company to cover any claims that might occur. I understand that if an ACV policy is purchased, the maximum limit for hull coverage is the actual cash value (ACV) at the time of the loss or the stated ACV above, whichever is less. The foregoing statements made and signed by the owner(s) represents the information set forth as correct and a true basis on which insurance may be granted but in no way binds the applicant to accept quotation or insurers to accept risk. FRAUD WARNING: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits. Your state may have specific warnings against filing false claim information. AZ For your protection Arizona law requires the following statement to appear on this form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties. CA For your protection California law requires the following to appear on this form: Any person who knowingly presents false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. NY Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed $_____________ and the stated value of the claim for each such violation. OR Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. PA Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of a claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. APPLICANT’S SIGNATURE: _________________________________________ DATE: ____________ PRODUCER’S SIGNATURE: ________________________________________________ DATE: ___________ TITLE (REQUIRED IF BOAT IS CORPORATELY TITLED) HOW LONG HAS THIS APPLICANT BEEN YOUR CLIENT? ___________ COMMERCIAL MARINE RENTAL WATERCRAFT VESSEL SCHEDULE UNIT ___________________________________________________________ YEAR ______________ MAKE AND MODEL _______________________________________________________ LENGTH _______________________________________________________________ HULL ID # (12 DIGITS) _________________________________________ ENGINE ______________________________________________________________ YEAR/MAKE __________________________________________________________ ENGINE SERIAL # ______________________________________________________ TOTAL HP ___________________________________________________________ MAX. SPEED __________________________________________________________ ACV 1 VALUE ____________________________________________________________ LIEN HOLDER NAME & ADDRESS: _________________________________________ _____________________________________________________________________ UNITS OF INTEREST _______________________________________________ LIEN HOLDER NAME & ADDRESS: _________________________________________ _____________________________________________________________________ UNITS OF INTEREST _______________________________________________ This vessel schedule is attached to and becomes part of the policy upon Company acceptance. All units must be identified and listed on the schedule in order to be covered under the policy. Additions or deletions to this schedule must be reported to the Company within 30 days of the change. List all outboard engines with the associated vessel. 1 Actual Cash Value