Owner's Details

Date

Vessel Owner's Name and Mailing Address:

Name*
Address
Birth Date
Boating Education / Licenses
Has any marine ins coverage ever cancelled or non-renewed?
Have you hade any MVR traffic violations in the past 5 years?
Do you have any Felony Convictions?

Prior Claim / Loss History (Paid or otherwise in the past five (5) years)

Date of Loss
$
Date of Loss
$
Is there any Corporate Ownership
Are there any other Named Operators?

Boat Details

Date of Purchase
$

Boat Description

Engines

Engine Type
Drive Type
On Board Equipment
Is there a lay-up or storage period?
If yes, the vessel stored

Trailer

$
Have the original engines been modified in any way?
Is the vessel used for water skiing?
Is the vessel used for any kind of towing?
Is the vessel used for any type of racing?
Is the vessel used for any type of chartering?

Bank Details

Bank / Leinholder / Loss Payee / Credit Union Name and Mailing Address

Bank Address

Additional Named Insured:

Name
Address
Requested Policy Effective Date

Coverages / Limits:

$
Hull Deductible
Protection and Indemnity
$

I agree that all of the information in this application is true and complete and that no material information has been concealed or misrepresented.  I agree that this Application and the terms and conditions of any insurance policy issued by the insurance company shall be the basis of any contract between the applicant and the insurance company, and that no insurance is in force unless and until confirmed in writing by the insurance company or, if authorized to do so, its agent.  I authorize the insurance company or its agent to investigate any information supplied by me, but it has absolutely no duty to do so.  I have the authority to sign this Application.

Any person who knowingly and with intent to defraud any insurance company or other personal files any application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime.  New York residents shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

IMPORTANT NOTICE REGARDING THE FAIR CREDIT REPORTING ACT: In making this application for insurance it is understood that as part of our underwriting procedure, an investigative consumer report may be prepared whereby information is obtained through personal interviews with your neighbors, friends, or others with whom you are acquainted.  This inquiry includes information as to your character, general reputation, personal characteristics and mode of living.  If an investigation is made, you can be assured that it will be handled in the strictest confidence.  If you wish information on the nature and scope of the Customer Report which may be requested, ask your agent for the address of the Company.

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