Insurance Watercraft AOR

INSURANCE WATERCRAFT AOR

This Appointment of Agent of Record (AOR) authorizes the named agent to act as agent of record for the watercraft insurance interests of the undersigned Insured for the coverages and policy(ies) specified below. Completion and signature of this form authorizes release of policy and claim information to the designated agent and constitutes a limited power to represent and manage placement and servicing of the identified watercraft insurance coverages.

Insured / Applicant Information

Client Name

Mailing Address

Date of Birth:    Phone:    Email:

Designated Agent

Agent / Agency Name

Agent Address:

Vessel Information

Vessel Year / Make / Model

Hull Identification Number (HIN):    Registration/State Number:

Length Overall (ft):    Vessel Type:    Home Port / Marina:

Primary Use of Vessel

Current / Prior Insurance

Current or Prior Insurer:    Policy Number:

Policy Period From:    To:

Scope of Appointment & Coverages

By signing below, Insured appoints the named agent as Agent of Record with authority to act on the Insured's behalf for the following coverages (check all that apply):

Hull / Physical Damage    Liability (Bodily Injury / Property Damage)    Medical Payments / PIP

Uninsured / Underinsured Watercraft    Towing & Assistance    Personal Effects

Other coverages / special endorsements:

Coverage Limits, Deductible & Premium

Requested Coverage Amounts / Limits

Preferred Deductible:    Estimated Annual Premium:

Desired Policy Effective Date:

Exclusions & Acknowledgements

Standard exclusions typically applicable to marine/watercraft policies include, without limitation: loss arising from willful misconduct of the operator, operation while under the influence of alcohol or drugs, racing unless specifically endorsed, wear and tear, gradual deterioration, and unrepaired hull defects. Coverage is subject to all policy terms, conditions and endorsements issued by the insurer. The Agent is not authorized to expand coverage beyond insurer-authorized endorsements without insurer approval.

I acknowledge and understand the exclusions and limitations described above and accept that final coverage and exclusions will be governed by carrier policy language.

Authorization, Representation & Consent

The Insured hereby appoints the named Agent as Agent of Record for the specified coverages. The Agent is authorized to receive insurance policy information, claims status, premium information, cancellation notices, and loss history from current and prior insurers and to represent the Insured in placement, negotiation of terms, and servicing of the policies indicated. This appointment does not itself bind coverage unless and until an insurer issues a policy in accordance with coverage selections and accepted terms.

The Insured certifies that all information provided on this form is true and complete to the best of the Insured's knowledge and that the Insured consents to the release of policy and claim information to the named Agent. The Insured agrees to indemnify and hold the Agent harmless for actions taken in reliance upon this appointment, except for acts of gross negligence or willful misconduct by the Agent.

Duration & Revocation

This appointment shall be effective as of: and shall remain in effect until revoked in writing by the Insured or until replaced by a subsequent written appointment. Revocation must be sent to the Agent and to any insurer for which the Agent is listed as Agent of Record.

Beneficiary for Salvage / Return of Property (Optional)

If salvage proceeds or recovered property resulting from a covered loss are payable and require designation for distribution, designate beneficiary below. This designation applies only for distribution of salvage or recovered property and does not create a primary insurable interest for policy purposes.

Beneficiary Name

Relationship:    Percentage of Proceeds:

Additional Instructions / Special Conditions

Certification

By signing below, I certify that the information provided is true and accurate. I authorize carriers and prior agents to release underwriting, policy and claim information to the named Agent of Record for the purposes of servicing, reviewing and placing watercraft insurance coverage. I understand that this authorization is limited to the functions described herein and does not guarantee placement of coverage unless accepted by an insurer.

I certify the foregoing and grant the authorizations above.

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