Insurance Application

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Please complete this application for EACH vessel.
Submit the Application along with the most recent survey.
THIS APPLICATION DOES NOT CONSTITUTE AN INSURANCE BINDER, NOR DOES IT CONVEY ANY INSURANCE COVERAGE WHATSOEVER.

Owner of Vessel
Operator of Vessel
Vessel Name
Date Built
Date Purchased
Vessel Builder
Date Engine Built
Overhauled
Hull Material
Engine Type
Type of Cruises Offered
Describe Navigation/Safety Equipment
Total Passengers
Average Passengers Per Trip
Operating Crew
Commissary Crew
Average Crew Number (Combined)
Area of Operation
from
to
Years in business
Total number of passengers carried annually
Describe or how food is served (sit down, buffet, catered, snack):
Please advise estimated receipts for alcohol (if any)
Have you ever had insurance cancelled/declined?
(If yes, explain)
Describe docking barges and work boats
Name & Years of experience of the Captains
List all owners and operators to be insured
List any parties you need to name as "additional insured"
When does your insurance expire?
What company insures you?
Hull Value
Deductible
Premium
Protection and Indemnity Limit
Deductible
Premium
Name of Mortgagee
FirstLast
Address of Mortgagee
Street AddressAddress Line 2CityState / Province / RegionZIP / Postal CodeCountry
Have you had any hull claims in the last five years?
(If yes, explain)
Have you had any protection & Indemnity claims in the last five years?
(If yes, explain)
Date
Telephone Number
Facsimile Number
Email Adress
Electronic Signature (Name)
Title