Agency Information

Agency Address

Producer

General Information

Mailing Address

Effective Date

HULL

$
$
$

Condition and Value Survey

Are survey recommendations complete?

Lay-up Period

Boat Operated by owner?

EQUIPMENT

Check all of the following equipment used on vessel:

Open winch bar guide:

Handrails on all companionways and weatherdeck:

Canister life raft/canopy:

Bridge tiles on weatherdeck:

Does vessel have a bilge alarm in good working order?

Does all safety and firefighting equipment meet U.S.C.G. requirements?

ENGINE

Is boat equipped with functioning hour meter?

Does Engine have high temperature and low oil pressure alarms?

TENDER COVERAGE

Is tender coverage needed?

Tender

$

Motor

$

Is over land transit coverage needed?

Trailer

$

PROTECTION AND INDEMNITY

Is this coverage desired?

Limit of Liability

OPERATOR/PREVIOUS INSURANCE/LOSS INFORMATION

Check box if no losses in past five years

Operator Information

Has any insurer within the past 5 years refused to renew, or canceled insurance to the applicant?

Renewal offered?

NOTICE OF INSURANCE INFORMATION PRACTICES - PERSONAL INFORMATION ABOUT YOU MAY BE COLLECTED FROM PERSONS OTHER THAN YOU IN CONNECTION WITH THIS APPLICATION FOR INSURANCE. SUCH INFORMATION AS WELL AS OTHER PERSONAL AND PRIVILEGED INFORMATION COLLECTED BY US OR OUR AGENTS MAY IN CERTAIN CIRCUMSTANCES BE DISCLOSED TO THIRD PARTIES WITHOUT YOUR AUTHORIZATION. YOU HAVE THE RIGHT TO REVIEW YOUR PERSONAL INFORMATION IN OUR FILES AND CAN REQUEST CORRECTION OF ANY INACCURACIES. A MORE DETAILED DESCRIPTION OF YOUR RIGHTS AND OUR PRACTICES REGARDING SUCH INFORMATION IS AVAILABLE UPON REQUEST. CONTACT YOUR AGENT OR BROKER FOR INSTRUCTIONS ON HOW TO SUBMIT A REQUEST TO US. ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OFMISLEADING INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS THE PERSON TO CRIMINAL AND [NY: SUBSTANTIAL] CIVIL PENALTIES. (Not applicable in CO, DC, FL, HI, MA, NE, OH, OK, OR, VT or WA; in LA, ME, TN and VA, insurance benefits may also be denied)

THE UNDERSIGNED IS AN AUTHORIZED REPRESENTATIVE OF THE APPLICANT AND REPRESENTS THAT REASONABLE ENQUIRY HAS BEEN MADE TO OBTAIN THE ANSWERS TO QUESTIONS ON THIS APPLICATION. HE/SHE REPRESENTS THAT THE ANSWERS ARE TRUE, CORRECT AND COMPLETE TO THE BEST OF HIS/HER KNOWLEDGE.

Berkley

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