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INSPECTED PASSENGER VESSELS
Full Name
Name of Insured
Date of Birth
Physical Address
City
State
Zip
Phone Number (Best)
Email Address
(Required to Submit)
*
# Years In Business
1
2
3
4
5
6
7+
Website:
AGENT YOU ARE WORKING WITH:
NONE
NICK MCGINTY
KERRY GONZALEZ
VANCE BARKER
GARRISON RUDISILL
Are you an EZ Waves Client
No
Yes
DUI / DWI Convictions
No
Yes
Felony Convictions
No
Yes
Filed for Bankruptcy
No
Yes
Has Insurance ever been Cancelled
No
Yes
When was it Cancelled, By Whom, & Why?
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
Primary Operator License:
6 Pack
25 Ton
50 Ton
75 Ton
100 Ton
+ 100 Ton
Any Claims (Operator)
Yes
No
Any Claims (Business)
Yes
No
Primary Operator # Yrs Boating
Primary Operator # Yrs Owned Boats
# of Prior Boats Owned
None
1
2
3
4+
Prior Vessels - 1
Prior Vessels - 2
Prior Vessels - 3
Operator Claim Details (Date, Amount, What Happened)
Business Claim Details (Date, Amount, What Happened)
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
1979
1978
1977
1976
1975
Pre 1975
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
Certificate of Inspection ~ Effective Date
Do you have a Tender?
Yes
No
Do you have a Trailer?
Yes
No
Survey Available?
Yes
No
Vessel Equipment
High Water Alarm
Fume Detector
Automatic Fire Extinguishers
Survey Information:
Survey Date
Survey Type
Out of Water
In Water
Upload Survey (Not Required)
Vessel Use
# Trips / Year
Use Type (Check all that apply)
Corporate Use
Fishing - Inshore
Fishing - Offshore
Sightseeing
Bed & Breakfast
Harbor Tours
Bareboat
Dinner Vessels
Water Taxi
Dive Charters
Other
Additional Charter Info:
Duration of Trips
Distance from Parking Area to Vessel
Is parking for passengers vehicles provided
Yes
No
Max # of Passengers
Is Docking Area Leased:
Yes
No
Lay Up Period?
Yes
No
Lay-up Period
Lay-up Type
Ashore
Inwater
Food Sevice
Yes
No
Alcohol Served
Yes
No
Do you get Certificates From Vendors?
Yes
No
Describe Food:
Catered From Outside
We prepare & serve
Prepared food
Type of Food Served:
Alcohol
Full Bar
Beer & Wine Only
Are Servers Trained for Alcohol Service
Yes
No
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)
Mooring Type
Residence / Trailer
Marina
Dry Stack
Other
Mooring Location - Hurricane Season
Marina Name
Other Location - Descibe
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
Atlantic 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%
Any additional Boats?
No
Yes
How Many?
*
1
2
3
4+
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
Additional Vessels
Year:
Make:
Length:
Engine Make:
# of Engines:
1
2
3
Horsepower
Insured Value:
Number of Passengers:
Year:
Make:
Length:
Engine Make:
# of Engines:
1
2
3
Horsepower
Insured Value:
Number of Passengers:
Year:
Make:
Length:
Engine Make:
# of Engines:
1
2
3
Horsepower
Insured Value:
Number of Passengers:
Misc.
ANY ADDITIONAL DETAILS YOU WISH TO SHARE
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