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YACHT APPLICATION
Full Name
Date of Birth (MO/DAY/YEAR: 12/01/2000)
Phone Number (Best)
Email Address
(Required To Submit)
*
Physical Address
Physical Address
City
State
Zip
Marital Status (Discounts Can Apply)
Married
Single
Divorced
Widow / Widower
Primary Residence:
Own
Rent
Agent you Are Working With:
NONE
NICK MCGINTY
KERRY GONZALEZ
VANCE BARKER
GARRISON RUDISILL
Boating History
Number of Years Boating - Total
# of Years Owning a Boat
Number of Claims
None
One
Two
Three
Four
Moving Violations Last 5 Years
None
One
Two
Three
Four
Boating Courses - Owner (Check all that apply)
USCG
Power Squadron
ASA
Sailing School - Other
State Boating Course
Other
License Held - Owner
None
USCG 6 Pack
USCG - 25 Ton
USCG - 50 Ton
USCG - 100 TOn
+100 Ton
Claim Details (Date, Amount, What Happened, Open / Closed) - Also note any non-filed incidents
Driving Infractions: Date / Description
Prior Vessels Owned
How Many Prior Vessels Have you owned
None
1
2
3
4+
Please Describe All Prior Vessels Operated: When, Length, Duration
Please List Prior Vessels Owned that are closest in length or Longer
Vessel 1 - Make
Number of Years Owned
1
2
3
4
5
6-10
10+
Vessel Length
Vessel 2 - Make
Number of Years Owned
1
2
3
4
5
6-10
10+
Vessel Length
Vessel 3 - Make
Number of Years Owned
1
2
3
4
5
6-10
10+
Vessel Length
Vessel Information
Hull Material
Fiberglass
Aluminum
Cold-Molded
Wood
Other
Hull Type
Mono-Hull
Catamaran
Trimaran
# of Yrs Owned
Purchase Date
Purchase Price
Year
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969 or Before
Year
Vessel Make
Model
Length
Vessel - Max Speed
10KT LESS
10-20KT
20-30KT
30-40KT
40-50KT
50-60KT
60-65KT
65KT+
Engine Make
Engine Year
Number of Engines
One
Two
Three
Four
HP - Each Engine
Fuel
Diesel
Gas
Engine Type
Inboard
Outboard
Inboard / Outboard (IO)
Survey Available?
Yes
No
Do you have a Tender?
Yes
No
Do you have a Trailer?
Yes
No
Survey Date
Survey Type
Out of Water
In Water
Upload Survey (Not Required)
Operator & Crew Information
Owner or Captain Operated
Owner
Full-Time Captain
Part-Time Captain
Do you employ paid crew
Yes
No
# Full-time Crew
1
2
3
4
5
6
7
8
9
10
# Part-time Crew
1
2
3
4
5
6
7
8
9
10
Vessel Use
How is Your Vessel Used:
Private Pleasure
Liveaboard
Private Please - With 10 or less Charters / Year
Private Please - With 10-20 Charters / Year
Full-Charter
# Yrs. Charter Experience
None
1
2
3
4+
# Passengers
Types of Charters
Corporate Use
Fishing
Sightseeing
Bed & Breakfast
Sailing School
Bareboat Charter
Other
Tender(s) / Trailer Information
Tender Details (Please as much as available): Year / Make / Length / Engine Make / Engine HP
Tender Value
Tender ~ Engine Value
Trailer Information (Include as much as available) Year / Make
Trailer Value
Vessel Navigation
Primary Mooring Location (City / State)
Primary Storage Location
Marina
Dry Stack
Residence - Dock/Lift
Residence Trailer
Other
Location During Hurricane Season
Marina / Dry Stack Name
Describe Other Location
Cruising Area - Primary
🛈
Inland Waters - Excluding Great Lakes
Inland Waters - Including Great Lakes
East Coast US - North of FLA Year Round
East Coast US, Florida, & Bahamas - No date Restrictions
Florida Waters Only
East Coast US, Florida, & Bahamas - North of FLA from 6/1-11/15
East Coast US, Florida, & Bahamas - North of FLA from 7/1-11/1
Caribbean
Gulf Of Mexico - US
Gulf Of Mexico - Mexico & Central America
West Coast US & Canada
Hawaiian Islands
West Coast Mexico & Central America
Panama Canal Crossing
Atlantic Crossing
Pacific Crossing
Other
Secondary Cruising (If Needed)
Inland Waters - Excluding Great Lakes
Inland Waters - Including Great Lakes
East Coast US, Florida, & Bahamas - No date Restrictions
East Coast US, Florida, & Bahamas - North of FLA from 6/1-11/15
East Coast US, Florida, & Bahamas - North of FLA from 7/1-11/1
Caribbean
Gulf Of Mexico - US
Gulf Of Mexico - Mexico & Central America
West Coast US & Canada
Hawaiian Islands
West Coast Mexico & Central America
Panama Canal Crossing
Atlantic Crossing
Pacific Crossing
Other
Additional Cruising Notes
Does The Vessel Lay-up?
Yes
No
Lay-up Dates (From / To)
Lay-up
Ashore
Afloat
Coverage Section
Insured Value Requested (Yacht)
Yacht - Deductible (as % of Value)
1%
2%
3%
4%
5%
Liability Limit
$300,000
$500,000
$1,000,000
$2,000,000
$3,000,000
$4,000,000
$5,000,000
More than $5MM
Uninsured Boater
$300,000
$500,000
$1,000,000
Over $1MM
Medical Payments
None
$1,000
$2,500
$5,000
$10,000
$15,000
$25,000
$50,000
$100,000
Personal Effects
None
$500
$1,000
$1,500
$2,500
$5,000
$10,000
$15,000
$25,000
$50,000
$100,000
Fishing Equipment
None
$1,000
$2,000
$3,000
$5,000
$10,000
$15,000
$25,000
$50,000
Tender Insured Value
Trailer Insured Value
Date Coverage is Needed
Current Insurance Carrier
Misc.
DUI / DWI Convictions
No
Yes
Felony Convictions
No
Yes
Filed for Bankruptcy
No
Yes
Has Insurance ever been Cancelled
No
Yes
Why was it Cancelled & by Whom?
Any Additional Details you would like us to know!
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