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 SSNPrimary Owner's Email Primary Owner's Marital StatusSingleMarriedPrimary Owner's Home Ownership/Residence StatusOwnRentPrimary Owner/Beneficial Owner's OccupationPrimary Owner/Beneficial Owner's Employer/Name of BusinessDoes primary operator hold a U.S.C.G. license?YesNoIs there a paid captain?YesNoAttach CopyAttach CopyDoes captain hold a U.S.C.G. license?YesNoTotal Number of Paid Crew (Including Captain)Attach CopyRegular OperatorsAdd one or multipleRegular Operator NameDOBBoating Courses? (Y/N)Driver License NumberState Does primary owner currently have insurance for this vessel?YesNoPrevious/Current Insurance CompanyPremiumHas owner ever had insurance canceled, non-renewed, or declined?YesNoCompany NameDate MM DD YYYY ReasonsHas any owner or operator sustained any marine claims or losses?YesNoCompany NameDate MM DD YYYY Amount PaidCauseDoes vessel have unrepaired damage or was it purchased as salvage?YesNoProvide Details Vessel & Equipment InformationPreviously Owned VesselsYears Owned TO-FROMYearMakeModelLength Vessel to be quotedYear BuiltLength (Feet)Builder/ManufacturerModel NameVessel Type (Power/Sail; Single/Multi-Hull)Purchase Price $Purchase Date MM DD YYYY Hull ID/Documentation NumberVessel's NameMaximum Speed (MPH)Hull MaterialFiberglassWoodSteelAluminumLast Marine Survey Date MM DD YYYY Mast Material (If Sailboat)Engine/Propulsion Drive SystemOutboardInboardI/OInboard/PODInboard/JetInboard/Surface PiercingNoneNumber of EnginesTotal H.P.Fuel TypeGas w/ No Fume DetectorGas w/ Fume DetectorHybrid/ElectricDieselEngine ManufacturerYear BuiltH.P. EachEngine Serial Numbers (Outboard Only Equipment (Check all that apply) Built-in Auto Fire Extinguishing System Fume Detector Carbon Monoxide Detector Alarm/ Monitoring System Alarm ManufacturerAlarm ModelAlarm TypeTrailer ManufacturerYear BuiltPurchase Date MM DD YYYY Trailer ValueTrailer Serial NumberTender/Dinghy Coverage OptionsTender/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$500Loss Settlement OptionAgreed ValueActual Cash ValueTender ValueIncluded (In vessel hull limit)Not included (in vessel hull limit) Tender YearManufacturerModelTender ValueLength (ft)Purchase Date MM DD YYYY Serial NumberMotor YearMotor ManufacturerSerial NumberMotor H.P.Motor Value (Outboards Only)Motor TypeOutboardInboardInboard/Outdrive Operation of VesselWaters to be navigatedLay up period (From MM/DD to MM/DD)If laid up, vessel is decommissionedAshoreAfloatAfloat w/BubblerBerth/Mooring Location of VesselMarina NameMooring 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 FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Berth/Mooring TypeAfloat at Dock/SlipAfloat at MooringOn Hydraulic LiftOn TrailerRack Storage (Inside)Rack Storage (Outside)On Jack Stands or StiltsVessel 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 charteredDays/year vessel is chartered with captain/crewMax passengers on vessel when charteredOther commercial purposes (details)Insurance Coverage RequestedProperty DamageLimitDeductibleLiability Coverage (Including Pollution)LimitDeductibleMedical Payments (per person)LimitDeductibleUninsured BoaterLimitDeductibleL&HCALimitDeductibleTrailerLimitDeductibleUnscheduled Personal PropertyLimitDeductibleTowing and AssistanceLimitDeductibleTender/DinghyLimitDeductibleOwner's Liability to Paid CrewLimitDeductibleSpecial Conditions/Other Coverages Loss Payee/Additional Insured InformationLoss PayeeAdditional InsuredName 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 FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country
