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6 PACK - CHARTER VESSELS
Applicant Information
Full Name
Name of Insured
Date of Birth
Physical Address
City
State
Zip
Phone Number (Best)
Email Address
(Must Enter to Submit)
*
AGENT YOU ARE WORKING WITH:
NONE
NICK MCGINTY
KERRY GONZALEZ
VANCE BARKER
GARRISON RUDISILL
Are you an EZ Waves Client
No
Yes
Website
# of Years Chartering?
0
1
2
3
4
5
5+
License Held - Primary Operator
USCG 6 Pack
USCG - 25 Ton Masters
USCG - 50 Ton Masters
USCG - 100 Ton Masters
DUI / DWI Convictions
No
Yes
Felony Convictions
No
Yes
Filed for Bankruptcy
No
Yes
Has Insurance ever been Cancelled
No
Yes
Insurance Cancelled: When, Why, & By Who:
Boating History
Number of Years Boating - Total
Yrs of Ownership
# Of Prior Vessels Owned
None
1
2
3
4+
Any Prior Claims?
Yes
No
Number of Claims
None
One
Two
Three
Four
1st Prior Vessel Owned - Include Years Owned, Make & Length
2nd Prior Vessel Owned - Include Years Owned, Make & Length
3rd Prior Vessel Owned - Include Years Owned, Make & Length
Claim Details (Date, Amount, What Happened)
Any Driving Violations - Last 5 Yrs
Yes
No
# Violations - 5 Years
None
One
Two
Three
Four
Description of Violation: (YR / Event / Outcome)
Vessel Information
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
Pre 1980
Year
Vessel Make
Model
Length
Vessel Name
Engine Make
Engine Year
Number of Engines
One
Two
Three
Four
HP - Each Engine
Fuel
Diesel
Gas
Hull Material
Fiberglass
Aluminum
Steel
Wood
Other
Vessel - Max Speed
10KT OR UNDER
10-20KT
20-30KT
30-40KT
40-50KT
50-60KT
60-65KT
65KT+
Purchase Date
Purchase Price
Do you lay-up the vessel?
No
Yes
Survey Available?
Yes
No
Survey Type
Out of Water
In Water
Survey Date
Do you have a tender?
Yes
No
Do you have a Trailer?
Yes
No
Vessel Equipment
High Water Alarm
Fume Detector
Automatic Fire Extinguishers
Upload Survey (Not Required)
Lay Up Dates: From - To:
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
# Charters / Annually
Under 10
10-20
20-25
25-50
50-75
75-100
100+
Types of Charters (Check all that Apply)
Corporate Use
Fishing - Inshore
Fishing - Offshore
Sightseeing
Bed & Breakfast
Harbor Tours
Bareboat
Other
Any Overnight Charters?
Yes
No
Max # of Passengers
Ave # of Passengers
For Overnight - Is the Captain on Board?
Yes
No
Additional Charter Info:
Will you provide/sell Food To Passengers?
Yes
No
What Types:
Water / Soda
Alcohol
Light Snacks
Full Meals
Please Provide Details on the Alcohol: Do you serve or hire out / What Types / Do you charge
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)
Location Type:
Residence
Marina
Dry Stack
Other Location
Marina Name
Other Location Detail:
Location During Hurricane Season - If Applicable:
Miles Offshore
0-5
5-10
10-15
15-25
25-50
50-75
75+
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
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
West Coast Mexico & Central America
Hawaii
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
West Coast Mexico & Central America
Hawaii
Panama Canal Crossing
Atlantic Crossing
Pacific Crossing
Other
Additional Cruising Notes
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
Uninsured Boater
$300,000
$500,000
$1,000,000
Medical Payments
None
$1,000
$2,500
$5,000
$10,000
$15,000
$25,000
Personal Effects
None
$500
$1,000
$1,500
$2,500
$5,000
$10,000
$15,000
$25,000
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.
Any Additional Details You wish to Share
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