Insurance AOR Boat

AGENT OF RECORD AUTHORIZATION — MARINE (BOAT)

This Agent of Record Authorization ("Authorization") appoints and authorizes the Agent identified below to act as Agent of Record with respect to boat insurance policies covering the vessel(s) and insured named in this form. Insured Name: . Policy Number (if known): .

Applicant / Insured Information

Date of Birth: / / .

Vessel Information

Primary Use (select all that apply): Recreational Commuting Fishing Charter / Commercial

Policy & Coverage Details

Current Insurer: Estimated Coverage Limit: Deductible:

Policy Period (if known): From / / to / / .

Coverage Types Requested / Authorized to Discuss (check all that apply): Liability Hull Personal Effects Uninsured/Underinsured Boater Towing & Assistance

Agent of Record Appointment

I, (the "Insured"), hereby appoint and designate the following as my Agent of Record for the above-referenced vessel(s) and insurance coverages:

Scope of Appointment: The Agent of Record is authorized to obtain, receive and review policy information, underwriting and claims history, certificates, endorsements, premium statements, and other records from current and prior insurers and agents with respect to the insured vessel(s) and related policies. The Agent is not authorized by this Authorization to bind coverage, alter coverage terms, or execute policy endorsements unless expressly granted separate written authority by the Insured or insurer.

Effective Date of Appointment (if different than signature date): / / .

Authorization to Release Information

By signing this Authorization, I authorize any current or prior insurer, managing general agent, claims administrator, or broker to release and disclose to the Agent of Record all policy documents, loss history, claims information, inspection reports, photographs, premium payment records, and other information reasonably related to my marine insurance coverages. This authorization extends to information relating to policies in force and policies previously issued.

Release Authorization: Authorize release of all records described above Authorize release of limited records only (specify below)

Exclusions & Limitations

The Agent of Record shall have no authority to:

1. Bind insurance coverage, accept coverage on behalf of an insurer, or execute policy endorsements unless specifically authorized in separate written documentation;
2. Admit liability or settle claims on behalf of the Insured or insurer;
3. Alter beneficiary designations for settlement proceeds except as expressly authorized in writing by the Insured.

Beneficiary Designation (Optional)

For the limited purpose of directing settlement proceeds in the event of total constructive loss of the vessel and where permitted by the policy, designate beneficiary(ies) below. Designation does not bind an insurer unless accepted in writing by the insurer.

Certification & Acknowledgment

I certify that the information provided in this Authorization is true and correct to the best of my knowledge. I understand that this Authorization does not by itself alter the terms or conditions of any insurance policy, nor does it authorize the Agent to bind coverage or settle claims except as expressly set forth in separate written documents. I acknowledge that I may revoke this Authorization at any time by providing written notice to the insurer and the Agent, but such revocation will not affect disclosures already made in reliance on this Authorization prior to receipt of revocation.

Indemnity: I agree to indemnify and hold harmless the Agent for actions taken in reasonable reliance upon this Authorization, except for willful misconduct or gross negligence by the Agent.

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