Personal Yacht Insurance
All Fields Marked(*) are Required
Insured's Personal Information

First Name:* Home Phone:
Last Name:* Work Phone:
Date of Birth (mm/dd/YYYY):* Cell Phone:
Company: Fax:
   
At least one phone number is required (*)
E-Mail:    
Address:* Marital Status:
  Occupation:
City: Vessel Name:
State:    
Postal Code:    
County:    

Coverage Effective: thru
Vessel Lay-up Period: Ashore Afloat
thru
   


Lienholder Information

First Name: Home Phone:
Last Name: Work Phone:
Company: Cell Phone:
Address:
 
City:
State:
Postal Code:

Coverages
 
Please Note: COVERAGES WILL NOT BE PROVIDED UNLESS REQUESTED HEREON

Coverages
Coverages Sum Insured ($)
Hull-Physical Damage:*
Liability:*
Personal Property:
Uninsured Boaters:
Medical Payments:
Trailer:
Commercial Passenger:
Crew Liability:
Tender/Dinghy:
Common Passenger:
Other: (Specify)




Equipment
Bilge Pumps: Aux. Generator Diesel:
Cooking Stove: EPIRB:
Flame Detector: Engine Alarm:
CO2/Halon System: Life Raft:
Fire Extinguishers: SONAR:
Anti-theft Devices: GPS:
Depth Sounder: Compass:
RADAR: SSB Radio:
LORAN/Direction Finder: Auto Pilot:
Ship to Shore Radio: Blower:
SATNAV/OMEGA Other:
(Listed Below)
Aux. Generator Gas:


Vessel Specifications

Primary Power*
Sail:
Outboard:
Inboard:
Inboard/Outboard:
Other Outboard:
Fuel Tank *
Metal:
Fiberglass:
Hull Description
Monohull
Catamaran

Type of Hull *
Sailboat:
Performance:
Other:
Sportsfisher:

Motor Yacht:

Houseboat:
Hull Material *
Wood:
Metal:
Fiberglass:
Aluminum:
Kevlar:
Carbon Fiber
Please detail all fire prevention/extinguishing
equipment installed or kept on vessel:

Vessel Information

Year:* Purchase Price: *
Length:(Feet)* Present Value: *
Date Purchased:
(mm/dd/yyyy)*		 Max Speed (Miles/Hour):
       
       
Manufacturer / Model:*
Lay-up in Storage location:

In Season Storage Location:
Registration Number:
Hull Identification Number:
Tender or Dinghy HIN:
Anti-theft precautions:
(Precautions against theft or damge)
Waters to be Navigated: *
Mooring Location:

Where do you plan to keep the vessel?
 
Do you have a current survey of your vessel?(Within the last 3 Years)
 
Date of survey?(mm/dd/yyyy)
   
Was survey Done Ashore?

Engine / Outboard Motor Information

Engine Horsepower Motor Year Date Purchased Puchase Price Present Value
1*
2
3
4

Engine
 Manufacturer / Model Serial Number
1*
2
3
4

Trailer Information

Year: Purchase Price:
Date Purchased: Present Value:
       

Manufacturer / Model
Serial Number:

Details of Previous Vessels


Operators

Always List Insured as Operator #1*
#
 Last Name First Name Date of Birth
(mm/dd/yyyy)		 State of Residence Boating Qualifications
1
2
3

#
Years Experience as
Violations / Suspensions
(Including Automobiles) in the last 5 Years
Operator
Owner
1
2
3

General Information

Explain All "Yes" Responses in Remarks *
Yes
No
Is the boat chartered to others with captain?
Is the boat chartered to others without captain?
Is the boat used for racing?
Is the boat used for water skiing or diving?
Is the boat used commercially or for business purposes?
Does the applicant employ a paid crew?
If So, How Many (Paid Crew)?
Was any operator involved in a marine loss in the last 10 years (Insured or not)?
Was any coverage declined, cancelled or non-renewed during the last 5 years?
Will the vessel be operated single handed at night?
Does anyone reside aboard the vessel?
Have you ever been convicted of a criminal offence or pleaded no contest?

If the boat is used for fare-paying passenger charters, what is the AVERAGE number of passengers per trip?    

If the boat is used for fare-paying passenger charters, what is the MAX number of passengers per trip?    
   
Number of Trips per Year?

Remarks

   

 
© 2009 Gregory Marine. All rights reserved. Terms and conditions.Designed by