Insurance Boat Application

Insurance Boat Application

Complete this application to request hull and liability insurance for the described watercraft. All answers must be true and complete to the best of the applicant's knowledge. Material misrepresentation, omission, or fraud may result in denial of coverage, rescission of the policy, or forfeiture of benefits.

Applicant Information

Applicant Name:

Date of Birth:

Watercraft Details

Length Overall (LOA): Fuel Type:

Number of Engines: Engine Make/Model: Total Horsepower:

Powerboat    Sailboat    Personal watercraft    Other:

Usage and Operation

Inland waters only    Coastal waters (within 20 NM)    Offshore (beyond 20 NM)

Operator Experience (years): Operator DOB:

Claims & Loss History

Have you or anyone who will be an insured had any marine losses, claims, or lawsuits in the past five years?    Yes    No

Policy & Coverage Requested

Hull    Liability    Medical Payments    Uninsured/Underinsured Boater

Effective Date:

Expiration Date:

Exclusions & Acknowledgments

The insured acknowledges that common policy exclusions may apply, including but not limited to: loss caused by war or hostilities, wear and tear, gradual deterioration, mechanical breakdown not resulting from a covered peril, intentional acts, operation by an unlicensed operator where license required, and operation beyond stated navigation limits. Acceptance of coverage is subject to underwriting review and verification of facts.

I acknowledge that I have read and understand the exclusions described above. Initials:

Loss Payee / Additional Insured

Beneficiary / Payee Designation

Beneficiary/Payee Name:

Relationship to Insured:    Percentage of Proceeds:

Attachments / Documentation Checklist

Please indicate documents attached:

Current registration / documentation    Photos of vessel and engines    Prior policy declarations

Declarations, Authorizations and Fraud Warning

By signing below, the applicant certifies that all statements in this application are true, complete and made with the intent that the insurer rely upon them in issuing a policy. The applicant authorizes the insurer and its representatives to obtain and verify any information deemed necessary, including loss history, claims reports, and consumer reports, to evaluate eligibility for insurance.

The applicant understands that any knowing misrepresentation, omission or concealment of a material fact may constitute insurance fraud and may be subject to state penalties including denial of claim or rescission of coverage. Premium, terms, and coverage are subject to underwriting acceptance and verification of the facts as submitted.

I authorize the undersigned insurer to provide a binder or policy based upon this application, subject to final underwriting approval. I acknowledge receipt of any required notices and agree that this application shall form the basis of any policy issued.

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