Insurance Yacht Application

INSURANCE YACHT APPLICATION

Applicant / Insured Information

Date of Birth:

Vessel Details

Hull Identification / IMO or VIN:

Year Built:    Make / Model:

Hull Material:    Hull Type:

Length Overall (LOA): ft    Beam: ft    Draft: ft

Gross Tonnage / Displacement:

Propulsion & Engines

Total Horsepower:    Propulsion Type:

Use, Navigation and Mooring

Primary Use:

Coverage Requested

Select coverage types requested:

Requested Policy Period From: To:

Safety Equipment & Theft Prevention

Indicate onboard safety and loss-prevention equipment:

Prior Insurance & Loss History

Have you had any losses, claims, cancellations or non-renewals in the past five (5) years?   Yes No

Survey / Maintenance

Date of Last Survey or Hull Inspection:

Mortgagee / Loss Payee / Beneficiary

Beneficiary / Payee Relationship:

Beneficiary Percentage of Loss Payment:

Exclusions, Warranties & Declarations

The undersigned warrants that all statements and particulars in this application are true and complete to the best of the applicant's knowledge and are material to the acceptance of the risk. Coverage is subject to the policy terms, conditions, limitations and exclusions, including without limitation exclusions for war, nuclear hazard, government seizure, intentional acts, wear and tear, ordinary depreciation, mechanical breakdown unless resulting from a covered peril, unseaworthiness known at inception that is not disclosed, and navigation or use outside declared limits.

The applicant agrees to maintain all safety equipment in serviceable condition and to notify the insurer promptly of any material change in the vessel's condition, ownership, operation, or location. If the vessel is used for charter or carrying passengers for hire, details of intended use and crew qualifications must be disclosed and accepted by the insurer.

The applicant authorizes the insurer or its representative to make inquiries and obtain reports relating to the vessel, prior insurance and claims history, and to inspect the vessel as reasonably necessary for underwriting or claims handling.

Attachments & Documentation

Attach copies of vessel registration or documentation, current or prior policy declarations, recent survey or hull inspection report, engine serial listings, and proof of qualifications or licensing for operators where applicable.

Certification & Signature

By signing below, the applicant certifies under penalty of perjury that the information provided in this application is complete and correct. The applicant acknowledges that any material misrepresentation or failure to disclose material facts may result in denial of coverage or rescission of the policy. The applicant further certifies that they are authorized to request coverage for the vessel described.

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