Date:
Your Name:
Your Email:
Vessel Name:

Agency:
Agency Code:
Name on Policy:

Mailing address:
City:
State:
Zip:

Occupation:

Yacht to Be Insured

Year Built:
Length:
Manufacturer:
Type:
Construction Material:
Total Horsepower:
Fuel Type: GasDiesel

Engine Manufacturer:
Engine Model:
Effective Date of Coverage:

Hull Insured Value:
Hull Deductible:
Liability Limit:
Medical Payments:
Personal Effects:
Uninsured Boaters:
Towing:

Tenders
(must be carried on board and used only to service the megayacht)
Year:
Mfr:
Length:
Horsepower:
Value:

Personal Watercraft
How Many:
Year:
Length:
Mfr:
Request for Charter: YesNo
Request for War: YesNo

Mooring/Navigating Area

Home Port:

Requested areas of navigation (check all that apply):
East Coast of the United StatesGulf Coast of the United StatesWest Coast of the United StatesVancouver Island, British Columbia, CanadaNewfoundland Island, CanadaBahamas, Turks & CaicosInland waters of the United States and CanadaPanama Canal TransitMexicoAlaskaBermudaEastern Caribbean, not south of GrenadaWestern Caribbean, not south of VenezuelaMediterranean navigationEuropean navigationTrans- Atlantic – Own bottomOther
Other Locations:

Cargo Shipment Required: YesNo
Name of cargo carrier:
Shipment dates:
City of departure:
Arrival city:
1 Year Itinerary:

Crew Information

Total # of full-time paid crew:
Total # of part-time/occasional crew:

Please check all that apply
Captain: Full TimePart TimeNone
First Mate: Full TimePart TimeNone
Engineer: Full TimePart TimeNone
Deckhand: Full TimePart TimeNone
Chef: Full TimePart TimeNone
Steward/Stewardess: Full TimePart TimeNone

Captain's name:
Captain's Resume:

Captain's Loss History:

Loss/Survey Information

Any Loss History: YesNo
If yes, please provide dates, description & amounts:

Survey available: YesNo
If yes, please attach copy

Previously Owned Vessels:
Previous Insurance Carrier:

Loss Payee

Name:
Mailing Address:
City:
State:
Zip:

Breach of Warranty required: YesNo
If so, Amount of Loan:

Additional Watercraft

First Craft
Year:
Length:
Manufacturer:
Model:
Value:

Second Craft
Year:
Length:
Manufacturer:
Model:
Value:

Are any of these watercraft towed behind the megayacht?
YesNo

If there is any additional information you'd like to add, please enter it below:

A quotation or policy issuance for this yacht is based upon information provided by the producer and prospective insured and is subject to receiving the Captain’s resume, the one year itinerary and a current survey (if applicable), within thirty (30) days from the quotation date.