Office: 561-927-0750
Cell: 561-305-2540
Email:Anthony@mycoastalins.com

Boat Application Form

Name Insured
Occupation
If Corporate, Beneficial Owner
Email
Phone Number
Home Number
Work Number
Cell Number
Address
City
State
Zip Code
Yacht Description
Year Built
Length
Manufacturer/Builder
Model
Hull Identification Number
Name of Yacht
Florida Registration
Vessel Flag
Date Purchased
Purchase Price
Engine Manufacturer/Model
Year Built
Serial Number(s)
Fuel Type
Propulsion
Engine(s)
Horsepower (each)
Max Speed (MPH)
Fuel Tanks
Auxiliary Generator
Navigation / Safety Equipment/ Security
Auto Fire Ext.
Fume Detector
Radar
GPS
Depth Finder
Auto Pilot
Hand Held Fire Extinguishers
Engine Alarm
VHF Radio
Theft Alarm
Tracking Device
Surveillance System
Locked/fenced enclosure
Secured building
Yacht Controller
If Other, Explain
Current Survey
Date of Survey
Storage
Name of Surveyor
Training/Experience
Years Boating Experience
Boating Courses
If Other, Explain

Boats Previously Owned
Dates Owned
Manufacturer
Type
Size
Waters Navigated
Dates Owned
Manufacturer
Type
Size
Waters Navigated
Dates Owned
Manufacturer
Type
Size
Waters Navigated
Dates Owned
Manufacturer
Type
Size
Waters Navigated
Other Operators
Age
Experience
Other Operators
Age
Experience

Loss History (if none, state NONE)
Details of any previous losses all operators
Date
Cause
Amount
Details of any previous losses all operators
Date
Cause
Amount
Details of any previous losses all operators
Date
Cause
Amount
Have you ever been convicted of a felony or DUI?
If Yes, Explain
Yacht Tender/Personal Watercraft/Trailer (may be insured separately for an additional premium)
Year
Lenght
Manufacturer
Model
Hull ID Number
Engine Year
Engine Manufacturer
Engine HP
Engine Serial Number
Trailer Year, Manufacturer & Model
Serial Number
No. of Axles
Capacity
Stored on Trailer
Insurance Coverages Requested
Yacht Hull and Machinery Amount of Insurance $
Deductible $
Named Windstorm Deductible $
Tender & Outboard Amount of Insurance $
Deductible $
Trailer Amount of Insurance $
Deductible $
Liability (P&I) Amount of Insurance $
Deductible $
Medical Payments Amount of Insurance $
Deductible $
Personal Effects Amount of Insurance $
Deductible $
Uninsured Boaters Amount of Insurance $
Deductible $
Crew Liability Amount of Insurance $
Deductible $
Navigation Area
Lay Up Dates From
To
Lay Up
Mooring Locations (Marina/Address, City, State, Zip Code)
June 1 to November 30
December 1 to June 1
Storage
If Other, Explain
Lienholder name and address
Additional Insured name and address
Loan Number
Loan Balance
Other Information
Is yacht ever chartered to others with captain?
If Yes, Explain
If yes, is yacht owner operated?
If Yes, Explain
Is yacht ever chartered to others without captain?
If Yes, Explain
Is yacht used commercially or for business purposes?
If Yes, Explain
Do you employ a paid captain or crew?
If Yes, How Many?
Number of full time crew
Number of part time crew
Do you live aboard full-time?
If Yes, Explain
Has any carrier cancelled or non-renewed coverage?
If Yes, Explain
Is the yacht used for racing?
If Yes, Explain
For fare paying passenger vessels, advise the maximum # of passengers per trip
For fare paying passenger vessels, advise the average # of passengers per trip
No. of trips
annually

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