Marine Insurance Prefer to fill out by hand? Click here to download a printable version Step 1 of 6 16% Insured InformationPolicy to be issued in the name of: Residence Address Street Address City State / Province / Region ZIP / Postal Code Mailing Address (If Different) Street Address City State / Province / Region ZIP / Postal Code Name of Owner (If Different)/Additional Owner First Middle Last Residence Address of Owner Street Address City State / Province / Region ZIP / Postal Code Billing Address of Owner (If Different) Street Address City State / Province / Region ZIP / Postal Code Owner/Operator InformationPrimary Owner's Phone NumberPrimary Owner's SSN Primary Owner's Email Primary Owner's Marital Status Single Married Primary Owner's Home Ownership/Residence Status Own Rent Other Primary Owner/Beneficial Owner's Occupation Primary Owner/Beneficial Owner's Employer/Name of Business Does primary operator hold a U.S.C.G. license? Yes No Is there a paid captain? Yes No Attach CopyMax. file size: 100 MB.Attach CopyMax. file size: 100 MB.Does captain hold a U.S.C.G. license? Yes No Total Number of Paid Crew (Including Captain)Attach CopyMax. file size: 100 MB.Regular OperatorsAdd one or multipleRegular Operator NameDOBBoating Courses? (Y/N)Driver License NumberState Add RemoveDoes primary owner currently have insurance for this vessel? Yes No Previous/Current Insurance Company Premium Has owner ever had insurance canceled, non-renewed, or declined? Yes No Company Name Date Month Day Year Reasons Has any owner or operator sustained any marine claims or losses? Yes No Company Name Date Month Day Year Amount PaidCause Does vessel have unrepaired damage or was it purchased as salvage? Yes No Provide Details Vessel & Equipment InformationPreviously Owned VesselsYears Owned TO-FROMYearMakeModelLength Add RemoveVessel to be quotedYear Built Length (Feet)Builder/Manufacturer Model Name Vessel Type (Power/Sail; Single/Multi-Hull) Purchase Price $Purchase Date Month Day Year Hull ID/Documentation Number Vessel's Name Maximum Speed (MPH)Hull Material Fiberglass Wood Steel Aluminum Other Last Marine Survey Date Month Day Year Mast Material (If Sailboat) Engine/Propulsion Drive System Outboard Inboard I/O Inboard/POD Inboard/Jet Inboard/Surface Piercing None Number of EnginesTotal H.P.Fuel Type Gas w/ No Fume Detector Gas w/ Fume Detector Hybrid/Electric Diesel Engine ManufacturerYear BuiltH.P. EachEngine Serial Numbers (Outboard Only Add RemoveEquipment (Check all that apply) Built-in Auto Fire Extinguishing System Fume Detector Carbon Monoxide Detector Alarm/ Monitoring System Alarm Manufacturer Alarm Model Alarm Type Trailer Manufacturer Year Built Purchase Date Month Day Year Trailer ValueTrailer Serial Number Tender/Dinghy Coverage Options Tender/Dinghy Not Scheduled (No Charge) Tender/Dinghy Scheduled (Charge) Actual Cash Value and Vessel Hull Deductible Amount applies (Not Scheduled) However, if policy type is Yachtsman or Boatsman, then tenders 17 ft or less in length with motor 40 hp or less are subject to $250 deductible Deductible Option $250 $500 Loss Settlement Option Agreed Value Actual Cash Value Tender Value Included (In vessel hull limit) Not included (in vessel hull limit) Tender Year Manufacturer Model Tender ValueLength (ft)Purchase Date Month Day Year Serial Number Motor Year Motor Manufacturer Serial Number Motor H.P.Motor Value (Outboards Only)Motor Type Outboard Inboard Inboard/Outdrive Operation of VesselWaters to be navigatedLay up period (From MM/DD to MM/DD) If laid up, vessel is decommissioned Ashore Afloat Afloat w/Bubbler Berth/Mooring Location of VesselMarina Name Mooring Address Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Berth/Mooring Type Afloat at Dock/Slip Afloat at Mooring On Hydraulic Lift On Trailer Rack Storage (Inside) Rack Storage (Outside) On Jack Stands or Stilts Other Vessel is (Check all that apply) Raced in other than club races Lived aboard on a permanent/semi-permanent basis Bareboat Chartered Chartered with Captain/Crew Stored on trailer at apartment/condominium Used for other commercial purposes Days/year vessel is bareboat chartered Days/year vessel is chartered with captain/crew Max passengers on vessel when charteredOther commercial purposes (details) Insurance Coverage RequestedProperty DamageLimitDeductible Liability Coverage (Including Pollution)LimitDeductible Medical Payments (per person)LimitDeductible Uninsured BoaterLimitDeductible L&HCALimitDeductible TrailerLimitDeductible Unscheduled Personal PropertyLimitDeductible Towing and AssistanceLimitDeductible Tender/DinghyLimitDeductible Owner's Liability to Paid CrewLimitDeductible Special Conditions/Other Coverages Loss Payee/Additional Insured Information Loss Payee Additional Insured Name First Middle Last Address Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country CommentsThis field is for validation purposes and should be left unchanged. 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