MARINE YACHT HULL & MACHINERY INSURANCE PROPOSAL FORM
Insured’s Name / Address :
Vessel :
Covers Required : / Sum Insured
Hull & Machinery
War Risks
Tender
Personal Property
Medical Expenses
Uninsured Boaters
Protection & Indemnity
Crew Liability
Passenger Liability
Pollution Liability
Electronics
Towing
Trailer
Navigation details :

Personal Details

Have you ever had a CCJ / Debt Judgement or been made bankrupt during the last five years? / YES / NO
If YES please provide additional details :
Have you ever been refused insurance, had special terms imposed or had a policy cancelled? / YES / NO
If YES please provide additional details ::
Have you any current convictions, police cautions or pending prosecutions (other than motoring convictions)? / YES / NO
If YES please provide additional details :
Have you 3 years experience and no claims in the last 5 years / YES / NO
If NO please provide additional details :
Do you possess a recognised yachting qualification / YES / NO
If YES please provide additional details :

Vessel Details

Is the vessel used for Private and Pleasure use or Charter Hire / YES / NO
Is the vessel powered by Motor or Sail
What is the Vessel Length
Who was the Builder
In what year was the vessel built
What is the Maximum Designed Speed
What are the Engines (number and type)
Additional details:
Does the Vessel have any Surface Drives / YES / NO
What is the hull construction type
Does the vessel have automatic fire extinguishers / YES / NO
What is the Class
The Vessel Flag
The mooring Country
If moored in USA, in which State
If moored in Florida, in which County
Where is it normally moored
In what Berth Number
How many Crew do you have
Professional crew / YES / NO
If YES please provide additional details :
Is the vessel diesel powered only (sailing yachts) / YES / NO
Is there any racing / rally use / YES / NO
If YES please provide additional details :
Is the vessel a catamaran / YES / NO
Is the vessel a trimaran / ferro / YES / NO

Navigation Details

Do you navigate in Inland waters only / YES / NO
If NO please provide additional details :
Are you intending to navigate around New Zealand / Australia / YES / NO
If YES please provide additional details :
Are you intending to navigate around the Mediterranean Sea / Europe / YES / NO
If YES please provide additional details :
Are you intending to navigate around the West Coast of USA / Mexico / YES / NO
Are you intending to navigate around North of Cabo San Lucas from 15/06 to 15/10 / YES / NO
Are you intending to navigate around Chesapeake Bay and North from 01/06 to 01/11 / YES / NO
Are you intending to navigate around Cuba / Columbia / Haiti / Venezuela / YES / NO
Are you navigating single handedly / YES / NO
Will there be any Trans Pacific navigation (one way) / YES / NO
If YES please provide additional details :
Will there be any Trans Pacific navigation (return) / YES / NO
If YES please provide additional details :
Will there be any Trans Atlantic navigation (one way) / YES / NO
If YES please provide additional details :
Will there be any Trans Atlantic navigation (return) / YES / NO
If YES please provide additional details :
Will there be any Indian Ocean navigation (one way) / YES / NO
If YES please provide additional details :
Will there be any Indian Ocean navigation (return) / YES / NO
If YES please provide additional details :
Will there be any Hawaii navigation (one way) / YES / NO
If YES please provide additional details :
Will there be any Hawaii navigation (return) / YES / NO
If YES please provide additional details :
Will there be any Bermuda navigation (one way) / YES / NO
If YES please provide additional details :
Will there be any Bermuda navigation (return) / YES / NO
If YES please provide additional details :
Will there be any Panama transit (one way) / YES / NO
If YES please provide additional details :
Will there be any Panama transit (return) / YES / NO
If YES please provide additional details ::

Cover Details

Law & Practice Jurisdiction / English / USA
Will you be Laying-up the vessel / YES / NO
If YES please provide additional details :
Do you wish to cover for lightning strikes / YES / NO
Do you require windstorm cover in "the Box" / YES / NO
If YES please provide additional details :
Any claims history in the last 5 years / YES / NO
If YES, was this a No fault claim
Please provide additional details ::
Additional information :
Signed
Name
Date

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