Agency Information

Agency Address

Producer

General Information

Mailing Address

Effective Date

Yard Location

Loss Payee

Inspection Contact

BUILDING(S)

Are buildings sprinklered?

Outside storage?

Is there a snow removal plan in effect, including rooftops?

YACHT DEALERS

List of major brands sold

Average monthly values for the past year

Do you exhibit in the water?

Do you do demonstrations with customers aboard?

YACHT DEALERS LIMITS AND DEDUCTIBLES

MARINA OPERATORS LEGAL LIABILITY

Ship Repairers

Type of work (by %)

Gross Receipts Last Two Years

Are trial runs performed after work is completed?

Storage: If Storage Only Coverage is provided does the insured winterize or prepare the vessel for storage?

Number of Vessels Stored:

Gross Receipts Last Two Years

Type of Storage (by %)

Are all buildings sprinkle red?

Docking and mooring

Gross Receipts Last Two Years

Fueling

Gross Receipts Last Two Years

Fire extinguishers present?

Who does fueling?

Hauling and Launching (Other than in connection with Ship Repairers or Storage)

Is regular maintenance performed on equipment?

Gross Receipts Last Two Years

PROTECTION AND INDEMNITY

PIERS, RAMPS AND FLOATS COVERAGE

Separate Fuel Dock?

Electricity on docks?

Is any property removed from water during winter?

OWNED WATERCRAFT

Trade Name Use of Boat Year Length H.P. Value $ Fuel Material of Hull

Lay-up period

PREVIOUS INSURANCE/LOSS 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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