Boat Owner *

Your Email *

Telephone *

Charter Co./Manager*

Address/City/State/Postcode*

Country *

Specify Flag/Registry*

Currency
EuroDollarBritish Pound

Years w/o Claims *

Make/Model *

Type *
MotorSail

Boat Name *

Year Vessel Built *

Year Vessel Purchased *

Purchase Price *

Previous Boats Owned *

Skipper Name/Date of Birth*

Boating Experience: Years/Type of Vessels/Navigation Areas *

Specify Mariner Qualifications*

Safety/Security Equipment
Auto Fire ExtFume DetectorRadarGPSDepth FinderAuto PilotHand Held Fire ExtEngine AlarmVHF RadioTheft AlarmTracking DeviceSurveillance SystemLocked/fenced enclosureSecured BuildingYacht Controller

Indicate desired amount or if no coverage is desired insert a zero:

Hull Machinery & Equipment: Insured Value

Road Trailer: Insured Value

Dinghy/Tender: Insured Value

Outboard Motor: Insured Value

Life Raft: Insured Value

Personal Effects: Insured Value

Total Sum Insured

Liability Limit - 10m Max
1,000,0002,000,0003,000,0005,000,00010,000,000

Waterski Liability
YesNo

Passenger Liability
YesNo

Crew Liability
YesNo
If yes, Number of crew

Boat Details - Length/Beam *

Maximum Speed - Knots *

Type of Construction *
—Please choose an option—AluminiumGRPGRP - hypalonWoodSteelOther

Engine Manufacturer/Year*

Engine HP*

Fuel*
GasDiesel

Type of Mooring *
—Please choose an option—SwingFore and AftChainPileMarina pontoonDry StackDry Stack - berthing

Mooring Country *

Marina *

Marina Address/City/State *

Cruising Areas - Please pick one

UK/Ireland/Inland Europe?
—Please choose an option—UKIrelandChannel IslandsEnglish ChannelEurope Inland

Mediterranean?
—Please choose an option—Med Waters not east of 10º (excl. territorial waters of Algeria)Med Waters not east of 20º (excl. territorial waters of Algeria & Libya)Med Waters not east of 30º (excl. territorial waters of Algeria, Libya and Egypt)Mediterranean Sea (excl. territorial waters of Algeria, Libya, Egypt, Syria, Lebanon and Israel)

USA/Canada?
—Please choose an option—East Coast U.SFloridaCaribbeanGulf CoastPacificInland - Great LakesInland - RiversInland - Others

Other Cruising Areas

Usage Details *
Skippered CharterBareboat Charter

Number of Charter Days *

Maximum Number of Passengers per Trip*

Have you made a claim in the last 60 months? *
YesNo
If yes, please provide details incl. amount. If no, insert none or n/a.

Has the proposer ever had an insurer decline a proposal? *
YesNo

Has the proposer ever had an insurer not invite renewal or cancel a policy? *
YesNo

Has the proposer ever had an insurer impose premium increases (other than normal rate increases) or special policy conditions? *
YesNo

Has the proposer ever been convicted or charged with a criminal offence? *
YesNo

Has the proposer ever been declared bankrupt or insolvent? *
YesNo

Effective Date of Cover * (YYYY-MM-DD)

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