Insurance Pontoon Application

INSURANCE PONTOON APPLICATION

Applicant / Insured Information

Applicant Name:

Date of Birth:    Phone:    Email:

Pontoon Vessel Details

Year:    Hull Identification Number (HIN):

Registration Number:    Length (ft):    Beam (ft):

Propulsion / Motor Information

Number of Motors:

Policy & Coverage Requested

Policy Period Start:    End:

Policy Type:   Agreed Value    Actual Cash Value

Liability Coverage — Limit: $ Deductible: $

Hull / Physical Damage — Limit: $ Deductible: $

Medical Payments — Limit: $    Uninsured/Underinsured Boater — Limit: $

Emergency Towing / Assistance — Limit: $    Personal Effects — Limit: $

Desired Annual Premium: $

Use, Operation & Navigation

Primary Use:   Private Pleasure    Rental / Charter    Commercial Fishing / Guide    Racing

Navigation Limits:   Inland Waters Only    Coastal (specify distance from shore):    Other (explain)

Safety & Security Equipment

USCG-approved life jackets for passengers    Fire extinguisher(s)    Bilge pump(s)

Distress signals / flares    GPS / Chartplotter    Engine cutoff / kill switch

Prior Insurance & Loss History

Previously Insured?   Yes    No   If yes, prior insurer:

Loss Payee / Mortgagee / Beneficiary

Relationship / Interest:   Coverage Interest Percentage:

Exclusions, Warranties & Important Notices

The applicant acknowledges that coverage will be subject to standard exclusions including, but not limited to: war, insurrection, intentional acts by the insured, wear and tear, gradual deterioration, mechanical breakdown not caused by a covered peril, loss resulting from operation of the vessel by an unlicensed operator where licensing is required, operation by an intoxicated operator, and any use for hire or carrying passengers for a fee unless expressly endorsed. The applicant warrants the information provided in this application is true and complete to the best of the applicant’s knowledge and that no material facts have been omitted.

I acknowledge I have read the exclusions and understand that failure to disclose material information may render coverage void or result in denial of claim payments.    I acknowledge and accept

Declarations & Consent

By signing below, the applicant declares that the answers and statements contained in this application are complete and true. The applicant authorizes the insurer to obtain and disclose information necessary for underwriting and claims handling, including inspection reports and loss histories. The applicant understands that coverage will be bound only upon acceptance and issuance of a policy by the insurer and that any material misrepresentation or omission may be grounds for denial of coverage or rescission of the policy. The applicant further consents to the insurer communicating with any listed loss payee or lienholder regarding coverage and claims.

Fraud Warning: Any person who knowingly and with intent to defraud any insurance company or other person files an application containing false information, or who conceals for the purpose of misleading, information concerning any fact material thereto, may be guilty of insurance fraud and subject to civil and criminal penalties.

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