Pleasure Yacht Application

A. Applicant Information
Applicant Name:
Address:
Address (cont.):
City:		State:	Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming	Zip:
Email:				Phone:
Effective date:

B. Loss Payee Information
Payee:
Address:
Address (cont.):
City:		State:	Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming	Zip:
% Financed:

C. Operators

Named Operators Date of Birth Affiliation To Owner 1. 2. 3.

D. Vessel Information
Builder/Manufacturer:
Model:
Hull ID/Serial #:
Year:		Length:
Vessel Name:
Date Purchased:		Purchase Price:
Construction:	Fiberglass Wood Aluminum Steel Other	Type:	Runabout Cruiser Sailboat Houseboat Other

E. Engine Information
Manufacturer:
Model:
Serial #(s):
Year:		Fuel Type:	Gas Diesel	Engine Type:	Outboard Inboard I/O Twin Single
Total HP:		Max Speed:
Generator Mfg:				Generator Fuel:	Gas Diesel

F. Equipment
Tender Mfg:		Length:		Value:		O.B. Value:
Trailer Mfg:		Value:		Serial #:
Number of Fire Extinguisher:
Built-in CO2/Halon: Yes  No		If 'Yes', auto or manual: Automatic  Manual
Anti-theft Devices: Yes  No		Other Safety Equipment:
Additional Equipment: VHF     Radar     Loran     GPS     Satellite/Navigation     Dept. Fdr     Fume Detector Auto Pilot     Other Equipment:

G. Personal Information
Years Boating:		Years as Owner:		Prior Owned:	(size/type)
Loss History:	(date, cause, amount)
Education:	USCGA USPS Licensed Capt. Other		Present Marine Insurer:
Is applicant living aboard: Yes No  Has your insurance ever been canceled or non-renewed: Yes No  If 'Yes', please explain:

H. Other General Information
Mooring/Docking
Summer:		Winter:
Navigation Area:		Mooring At Dock Trailered
Lay-up From: (12:01AM)  To:   On Land In Water
Do you employ a paid captain or crew? Yes No     If 'Yes', how many?
Most Recent Survey:
Is vessel ever chartered or used commercially? Yes No  If 'Yes', describe?
Is yacht used for racing? Yes No  If 'Yes', give details?

I. Coverage

Amount of Insurance Deductible Premium HULL & EQUIPMENT  $ $ $ OUTBOARD MOTORS  $ $ $ LIABILITY  $ $ $ MEDICAL PAYMENTS  $ $ $ PERSONAL EFFECTS  $ $ $ TRAILER/TENDER  $ $ $ FUEL SPILL  $ $ $ TOWING  $ $ $ UNINSURED BOATER  $ $ $ 1% Min. or $250 Which is greater, Trailer Deductible $100  Total Premium:  $

A survey, no older than 24 months, must be provided for vessels over ten years old. Please fax a copy of the survey along with your name to 925.677.7401. Recommendations must be completed within thirty days from inception date of policy.