ADVANCED E&S - YACHT APPLICATION (Preferred)

ADVANCED E&S - YACHT APPLICATION (preferred)

Date:______Agency:______

Name to be Used on Policy:______

Mailing address:______City:______State:______Zip:______

Beneficial Owner's Name:______Date of Birth: ______

Occupation:______Nationality: ______

Other entities or individuals having financial interest in this yacht: ______

Boats Previously Owned:

Dates Owned:______Builder:______Type:______Size:______Waters Navigated:______

Yacht To Be Insured:

Year Built:______Length:______Manufacturer:______Model:______Type:______

Hull #/Document #:______Vessel Name:______

Construction Material:______Tonnage: ______Engine Manufacturer:______Gas: ( ) Diesel: ( )

Engine Model:______Single:____Twin:____ Total Horsepower:______Max. Speed:______

Propulsion System: Traditional Shaft Driven:______Jet Drive:______Arneson/Surface Piercing:______

Purchase Date: ______Purchase Price:______Effective Date of Coverage______

Hull Insured Value: $______Hull Deductible: $______Wind Deductible:$______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:______

Engine Manufacturer: ______Horsepower: ______Inboard:___Outboard:___Jet:___Total Value: $______

Personal Watercraft: How Many: _____ Year: ______Length: ______Mfr.: ______Value:______

Year:______Length: ______Mfr: ______Value:______

Request for Charter: ( ) Yes ( ) No If yes, number of charters per year: ______

Is this yacht part of a Timeshare, Fraction Share, Vacation Club or similar type arrangement? ( ) Yes ( ) No

Request for War: ( ) Yes ( ) No Port of Registry:______

Mooring/Navigating Area:

Home Port Spring/Summer Including Zip Code:______

Home Port Fall/Winter Including Zip Code: ______Lay-up Dates:______to______

Requested areas of navigation: ( ) East Coast of the United States ( ) Gulf Coast of the United States ( ) West Coast of the United States

( ) Vancouver Island, British Columbia, Canada ( ) Newfoundland Island, Canada ( ) Bahamas, Turks & Caicos ( ) Inland waters of the

United States and Canada ( ) Panama Canal Transit ( ) Mexico ( ) Alaska ( ) Bermuda ( ) Eastern Caribbean, not south of Grenada

( ) Western Caribbean, not south of Venezuela ( ) Mediterranean navigation ( ) European navigation ( ) Trans- Atlantic – Own bottom

( ) Worldwide ( ) Other:______

One Year Itinerary:______

______

( )Cargo Shipment Required Name of cargo carrier: ______

Shipment dates: ______City of departure: ______Arrival city: ______

Crew Information:

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

Please check all that apply:

( )Captain ( )full-time ( )part-time Captain’s Name: ______

( )First Mate ( )full-time ( )part-time ( )Engineer ( )full-time ( )part-time

( )Deckhand #______; ( ) Steward/Stewardess #______; ( ) Chef

Loss/Survey Information:

Does the insured have any previous loss history:( ) Yes ( ) No If yes, please provide dates, description & amounts:

______

Does the Captain have any previous loss history: ( ) Yes ( ) No If yes, please provide dates, descriptions & amounts:

______

Does this yacht have any previous loss history: ( ) Yes ( ) No If yes and different from above, please provide dates, description & amounts:

______

Date of last Survey:______Survey available: ( ) Yes ( ) No. If yes, you are required to provide us with a copy.

Have all recommendations been complied with: ( ) Yes ( ) No.

If insured is not the original owner: What was the purchase date: ______

Is a copy of the pre-purchase survey available: ( ) Yes ( ) No. Original purchase price: $______

Name of Current/Previous Insurance Carrier: ______

Has your insurance ever been non-renewed: ( ) Yes ( ) No. If yes, please provide details: ______

______

Loss Payee: Name:______Mailing Address:______

City:______State:______Zip:______

Breach of Warranty required: ( ) Yes ( ) No If so, Amount of Loan: $______

Additional Watercraft:

Year Length Manufacturer Model Value __

Are any of these towed behind the yacht ( ) Yes ( ) No If yes, date of most recent tow/bridle survey:______(Please attach copy)

I declare that the answers above are true to the best of my knowledge and that all material facts related to the risk to be insured have been disclosed. I also agree that the information given herein shall form the basis upon which the insurance will be offered, as well as the basis for the insurance contract between me and the insurer if a policy is subsequently issued. Non disclosure or misrepresentation of any material fact related to the risk may result in the withdrawal of the offer and / or the nullification of the insurance policy.

______Date ______

Insured’s signature

ADVANCED E&S - YACHT APPLICATION (Preferred)

Year ______Length ______Manufacturer ______Model ______Value ______

Year ______Length ______Manufacturer ______Model ______Value ______

Year Length Manufacturer Model Value __

Year Length Manufacturer Model Value __