Insurance Waverunner Application

INSURANCE WAVERUNNER APPLICATION

Applicant / Insured Information

Phone:    Email:

Date of Birth:    Driver's License #:    State of Issue:

Waverunner / Vessel Details

Registered Owner (if different):

Make:    Model:    Year:    Length (ft):

Engine Type:    Horsepower:    Agreed Value / Stated Value: $

Use, Navigation & Safety

Primary Use: Pleasure / Recreational Racing Rental / Charter Commercial / Instruction

Navigation Limits: Inland waters only Coastal waters within miles Offshore (subject to underwriting approval)

Personal Flotation Devices Fire Extinguisher Engine Kill Switch / Lanyard Navigation Lights

Coverage Selection & Policy Details

Policy Period: From to

Coverage Options (select desired coverages and specify limits/deductibles):

Liability Coverage — Limit $ Deductible $

Hull / Physical Damage — Limit $ Deductible $

Theft Coverage — Limit $ Deductible $

Medical Payments — Limit $ Uninsured/Underinsured Boaters — Limit $

Claims History & Loss Information

Have you or any other operator on this policy had any marine-related claims, losses or violations in the past 5 years? Yes No

Exclusions, Conditions & Acknowledgements

The policy applied for will contain exclusions typical to personal watercraft insurance, including but not limited to: intentional acts or willful misconduct; operation while under the influence of alcohol or controlled substances; racing or speed contest (unless specifically endorsed); operation by an unlicensed or unauthorized operator; wear, tear, corrosion, mechanical or electrical breakdown; war, nuclear hazard and government seizure. Additional exclusions may apply by endorsement.

I acknowledge that issuance of coverage is subject to underwriting review and acceptance. I agree to notify the insurer of any change in usage, ownership, or material change in risk during the policy period. Failure to disclose material facts or any fraudulent statements may result in cancellation or denial of claims and may be punishable by law.

I have read and understand the exclusions and conditions stated above.

Beneficiary Designation (for Medical Payments / Death Benefits)

Relationship:    Percentage: %

Documentation Checklist

Please attach or provide copies of the following as applicable:

Current Registration Title or Proof of Ownership Photographs of Vessel Operator License(s) Police Report (if applicable)

Declarations & Certification

I declare that the information provided in this application is true, complete and accurate to the best of my knowledge. I understand that any misrepresentation or omission of material facts may result in denial of coverage, rescission of the policy, or criminal penalties where applicable. I authorize the insurer to obtain and verify information necessary for underwriting, including but not limited to prior claims, loss history, motor vehicle records, and to inspect the vessel.

I understand that completion of this application does not bind coverage. Coverage becomes effective only upon issuance of a policy by the insurer and payment of the required premium, subject to the terms, conditions and exclusions of the policy.

By signing below I certify under penalty of perjury that the foregoing statements are true and correct.

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