PLEASURE BOAT
INSURANCE
APPLICATION / QUESTIONNAIRE
Complete the following information if you would like to obtain a quote on a Motor
Home insurance policy. Please understand this is not an application for insurance.
An application will be sent to you if coverage is desired.
All information provided on this information sheet is confidential and will be used
solely for the purpose of developing a quote for you.
APPLICANT INFO EFFECTIVE DATE: _____________________ LOSS PAYEE INFO |
Owner’s Name ____________________________________ Address_____________________________ ___________________________________ City ________________________________ State _____________ Zip ______________ Phone ______________________________ Fax:________________________________ | Payee ______________________________ Address _______________________ ______________________________ City __________________________ State ___________ Zip __________ % Financed __________ |
GARAGING INFORMATION:
1. User’s Name:
2. User’s Address:
3. Mailing Address (if different:
City: State: Zip:
4. Contact Person: Person is: FORMCHECKBOX Owner FORMCHECKBOX Manager
FORMCHECKBOX Promoter FORMCHECKBOX Mgmt FORMCHECKBOX Other:
5. Phone: Fax #: E Mail:
DRIVER INFORMATION:
Driver #1:
Name: Gender: FORMCHECKBOX Male FORMCHECKBOX Female
Birthdate: Marital Status: Years Boating Experience
State Licensed: Occupation:
Driver #2:
Name: Gender: FORMCHECKBOX Male FORMCHECKBOX Female
Birthdate: Marital Status: Years Boating Experience tate Licensed: Occupation:
Driver #3:
Name: Gender: FORMCHECKBOX Male FORMCHECKBOX Female
Birthdate: Marital Status: Years Boating Experience
State Licensed: Occupation:
Driver #4:
Name: Gender: FORMCHECKBOX Male FORMCHECKBOX Female
Birthdate: Marital Status: Years Boating Experience ___ __
State Licensed: Occupation:
TOWING
AUTO INFORMATION:
Vehicle #1:
Year: Make: Model: TYPE:
Cost New Value: $ Identification Serial #:
Hours Used Each Year: Boat Length: Watercraft Weight Ownership:
Lienholder: Name
Address:
City/State/Zip:
Vehicle #2:
Year: Make: Model: # of CC’s
Cost New Value: $ Identification Serial #:
Hours Used Each Year: Boat Length: Watercraft Weight Ownership:
Lienholder: Name
Address:
City/State/Zip:
Vehicle #3:
Year: Make: Model: # of CC’s
Cost New Value: $ Identification Serial #:
Hours Used Each Year: Boat Length: Watercraft Weight Ownership:
Lienholder: Name
Address:
City/State/Zip:
Vehicle #4:
Year: Make: Model: # of CC’s
Cost New Value: $ Identification Serial #:
Hours Used Each Year: Boat Length: Watercraft Weight Ownership:
Lienholder: Name
Address:
City/State/Zip:
TRAILER INFORMATION:
Vessel | Builder/Manufacturer Model Hull ID / Serial # __________________________________________________________________________________________________________________ Year_______________ Length __________ Construction Type Vessel Name__________________________ FORMCHECKBOX Fiberglass FORMCHECKBOX Wood FORMCHECKBOX Runabout FORMCHECKBOX Cruiser Date Purchased _______________________ FORMCHECKBOX Aluminum FORMCHECKBOX Steel FORMCHECKBOX Sailboat FORMCHECKBOX Houseboat Purchase Price $______________________ FORMCHECKBOX Other FORMCHECKBOX Other |
Engine | Engine Year Engine Mfg. Model Serial #’(s) ________________________________________________________________________________________ Fuel FORMCHECKBOX Gas Type FORMCHECKBOX Outboard FORMCHECKBOX Twin Total H.P. ________ Generator Mfg. _____________ FORMCHECKBOX Diesel FORMCHECKBOX Inboard FORMCHECKBOX Single Max Speed _______ FORMCHECKBOX Gas FORMCHECKBOX Diesel FORMCHECKBOX I / O Applicant’s Initials ____________ |
Equipment | Tender Mfg: _________________________ Length: _________ Value: __________ O.B. Value___________ Trailer Mfg: _________________________ Value: ___________ Serial #:____________________________ FORMCHECKBOX VHF FORMCHECKBOX GPS FORMCHECKBOX Fume Dtr Number of Fire Extinguishers ___________________________ FORMCHECKBOX Radar FORMCHECKBOX Sat/Nav FORMCHECKBOX Auto Pilot FORMCHECKBOX Built in CO2/Halon FORMCHECKBOX Manual FORMCHECKBOX Automatic FORMCHECKBOX Loran FORMCHECKBOX Dept. Fdr FORMCHECKBOX Other FORMCHECKBOX Anti-theft Devices FORMCHECKBOX Other Safety Equipment |
Personal | Years Boating __________ Years as Owner _________ Prior Owned (size and type) ________________________________ Loss History: (Date, Cause, Amount) ________________________________________________________________ Education: FORMCHECKBOX USCGA FORMCHECKBOX Licensed Capt. Present Marine Insurer: ______________________________ FORMCHECKBOX USPS FORMCHECKBOX Other Is applicant living aboard? FORMCHECKBOX Yes FORMCHECKBOX No Has your insurance ever been canceled or non-renewed? FORMCHECKBOX Yes FORMCHECKBOX No |
General | Mooring/Docking: Summer___________________________ Winter _____________________________ Navigation Area: ________________________________________ FORMCHECKBOX Mooring FORMCHECKBOX At Dock FORMCHECKBOX Trailered Lay-up From: ______________ (12:01 AM) To: ______________ FORMCHECKBOX On Land FORMCHECKBOX In Water Do you employ a paid Captain or crew? FORMCHECKBOX Yes FORMCHECKBOX No How many? ________ Most recent survey?___________ Is vessel ever chartered or used commercially? FORMCHECKBOX Yes FORMCHECKBOX No ________________________________________ Is yacht used for racing? FORMCHECKBOX Yes FORMCHECKBOX No (details) _________________________________________________ |
AMOUNT OF INSURANCE DEDUCTIBLE PREMIUM |
Coverages | HULL & EQUIPMENT $_________________________ $______________________ $_____________ OUTBOARD MOTORS $_________________________ $______________________ $_____________ LIABILITY $_________________________ $______________________ $_____________ MEDICAL PAYMENTS $_________________________ $______________________ $_____________ PERSONAL EFFECTS $_________________________ $______________________ $_____________ TRAILER/TENDER $_________________________ $______________________ $_____________ FUEL SPILL $__________________________ $______________________ $____________ TOWING $__________________________ $______________________ $_____________ UNINSURED BOATER $_________________________ $______________________ $_____________ 1% Min. or $250, whichever is greater, Trailer Deductible $100. Total Premium: $_______________ |
VIOLATION INFORMATION:
Last three (3) years (minor violations). Last five (5) years (major violations).
| Driver #1 | Driver #2 | Driver #3 | Driver #4 |
Minor violations – speeding, turn, stop sign, red light, etc. | | | | |
Accidents – non chargeable | | | | |
Accidents – chargeable | | | | |
Major violations – drunk driving, reckless, hit & run, etc. | | | | |
COVERAGE INFORMATION:
| Bodily Injury | Property Damage |
Personal Liability Limits | | |
Uninsured Motorist Limits | | |
Medical Payment | | |
DEDUCTIBLE INFORMATION:
Vehicle #1 |
Vehicle #2 |
Vehicle #3 |
Vehicle #4 |
Comprehensive (Theft) | |
Collision | |
Comprehensive (Theft) | |
Collision | |
Comprehensive (Theft) | |
Collision | |
Comprehensive (Theft) | |
Collision | |
MISCELLANEOUS INFORMATION:
Does the Boat have a Fire System? | FORMCHECKBOX Yes FORMCHECKBOX No | |
Any Commercial Usage? | FORMCHECKBOX Yes FORMCHECKBOX No | |
What is the Fuel Type? | | |
List Electronic Aids in the Boat? | | |
Current Insurance Company: | |
Expiration Date: | Mo: Day: Yr: |
Current Premium: | $ |
Questions or Comments: | |
| | | | |
Please let us know the best time to call and discuss your quote:
FORMCHECKBOX Morning FORMCHECKBOX Afternoon FORMCHECKBOX Evening FORMCHECKBOX Anytime FORMCHECKBOX Other:
I hereby declare that I personally have read this application and declare that the Statements made are true. I understand that this is not a binder of insurance. 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, any information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime. Applicant’s Signature____________________________________________ Date:______________________________ |
A survey, no older than 24 months, must accompany application for vessels for vessels over ten years old. Recommendations must be completed within thirty days from inception date of policy.
STATE LICENSED AGENT
F. DARRELL LINDSEY – ALL STATES
P. O. Box 526357
Salt Lake City, UT 84152-6357
PH: 801-937-7037
FX: 800-694-6363
E-Mail: fdl@LLLindsey.com
California Office License No#: OC13511 – Robby L. Lindsey
