Charter Boats Insurance Quote Form

by W.R. Hodgens Marine Insurance, Inc.

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Charter Yacht Insurance Quote

Please complete the following in as much detail as possible to assure we can provide you with the most competitive rate, or phone us at 1-800-990-WAVE (9283) for an immediate charter insurance quote.

INSURED INFORMATION

Name of Insured (as will read on the policy):

Owner’s Name:

Effective Date:

Corporate Name
(if any):

Is Corporation for sole purpose of ownership of vessel? Yes No

If no, explain:

Address:

City:

State: Zip:

Phone: Home:

Business:

Email:

Present Insurer:

Exp. Date:

Prior Vessels Owned or Operated:

YEAR	TYPE	LENGTH	HOW LONG OWNED

Losses in past 5 years? (on any vessel):
Yes No

If yes, please list date, type, amount and status.

Hull Claims:

P&I Claims:

VESSEL INFORMATION

Vessel Name:

Year:

Make:

Model:

Length:

Construction: Steel Fiberglass Wood
Aluminum Other

Other:

Hull ID/Serial #:

Replacement Cost:

Has vessel been Coast Guard Inspected:
Yes No

If yes, how many passengers is it certified for:

Doc. #:

Is vessel more than 6 passenger: Yes No

Date of Vessel’s
Last Survey:

Surveyed by whom:

Purchase Date:

Purchase Price:

Amount Financed:

Loss Payee:

Address:

ENGINE INFORMATION

Year:

H.P. Per Engine:

Max Speed:

NUMBER: Single Twin

TYPE: Gas Diesel

Manufacturer:

Serial Numbers:
P S

Is vessel equipped with the following:

Yes No	High Water Level Alarm (Outboard only)
Yes No	Fume Detectors
Yes No	Automatic Fire Extinguishing System with Manual Override

NAVIGATION DETAILS

Maximum # passengers any one trip:

Home Port: Marina Private Residence Other:

Waters Navigated:

Type of Charters: Any overnight charters? Yes No

Do passengers swim, snorkel, scuba dive or water ski for the insured vessel: Yes No

If yes, explain:

Average Number of Charters per Year:

Lay up period (if any): From: To: On Land On Water

If lay up period, give location:

Is this vessel being held for sale? Yes No

CAPTAIN INFORMATION

Is vessel Captain owned? Yes No

Total Number of Crew:

Captain Name:

D.O.B.:

Years with Insured:

Prior Experience:

Does Captain have a current USCG “Operator of Uninspected Passenger Vessel License”? Yes No

Other Licenses and Certifications:

Name of each crew member, job each performs and years with Insured

NAME	JOB DESCRIPTION	YEARS WITH INSURED

COVERAGES

	LIMIT	DEDUCTIBLE	PREMIUM
Hull
Trailers
Personal Effects
P&I
Towing
Uninsured Boaters
Fuel Spill Liability
Med Pay

You understand and agree this application is a request for a quote based on the information provided herein. You understand and agree the actual coverage, terms and conditions offered may be different than your request contained herein. The actual terms and conditions for coverage provided are represented by the policies issued and supersede any request or representations made prior to issuance.

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime.