MARINE INSURANCE APPLICATION

MARINE INSURANCE APPLICATION
Please complete the following application in order to be considered for a marine insurance policy.

If you have any questions while completing this form, please contact Jackie@MyYachtSales.com

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If you need financing for your new vessel,

please CLICK HERE

If you need documentation services for the purchase of your new vessel,

please CLICK HERE
Name or LLC *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Mailing Address (IF DIFFERENT FROM ABOVE)
Do you Own, Rent, or have a business more than 4 hours or 150 miles away from your vessels mooring location?

YES NO Other
Phone Number *
Please enter a valid phone number.
Email Address *
example@example.com
Occupation *
Date of Birth *

Month Day Year
Date
Driver's License Number *
Marital Status *

Single Married Divorced Separated Widowed
Gender

Male Femail
Homeownership Status

Own Home Rent Home Live with relatives Other
Year of Vessel *
Length of Vessel *
in Feet
Make and Model of Vessel *

MAKE MODEL
Hull ID
Date of Purchase

Month Day Year
Can be in the future
Purchase Price (can be different than insured value) *
Will this vessel be for sale again within the next 3-6 months? *

YES NO
Number of Engines *
Engine(s) MAKE *
Engine(s) MODEL
Horsepower of Each Engine *
Model Year of Engines *
Type of Engine (if other, please specify below) *
Specify Other Type of Engine
Engine Serial Numbers (IF MULTIPLE NUMBERS, PUT SLASH "/" IN BETWEEN)
Fuel Type *
Hull Material (Fiberglass, Aluminum, Steel, Wood, Other)
Do you have a current survey for this vessel? If YES, upload at the bottom of this form. *

YES NO No, but one will be scheduled
GPS Tracking

SPOT GHOST ATLASTRAX Other
Have you owned or operated a watercraft previously? *

OWNED OPERATED OWNED AND OPERATED NO
What watercraft have you owned OR operated previously & for how long? Please specify (i.e. Owned 24ft Cobia - 6yrs)
From your previous vessels, are there any insurance claims or losses within the past 3-5 years? *

YES NO
How will the vessel be used? *

PRIVATE / RECREATIONAL PRIVATE WITH LIGHT CHARTER FULL TIME CHARTER CHARTER (6-PACK) LIVE-ABOARD/RESIDENCE Other
In the past on a vessel, have you had any Accidents or Tickets? (i.e. DUI/ Major Accident/Vehicular Homicide/ Reckless Driving) *

YES NO
Have you taken any additional safety courses or do you have a captains license?

USCG Safety Course Power Squadron Captain's License Other
Please add the address where the watercraft will be kept if it is different from your home address (If different, please specify ENTIRE ADDRESS and MARINA or LOCATION NAME)
How will the watercraft be stored? *
Will the vessel be financed?

YES NO
If yes, please specify Bank or Lender or N/A if unsure
Additional Insured (i.e. Marina Name, Family Member, Friend/Partner that will need to be on the policy)
Would you like your trailer insured? *

YES NO
Make of Trailer
Value of Trailer
in USD
Year of Trailer
Trailer Serial Number
Insured Value of Watercraft (minus Trailer) *
in USD
Protection & Indemnity / Uninsured Boater Liability Limits

$300,000 $500,000 $1,000,000 $2,000,000
Medical Payments
Personal Effects
Bahamas Coverage Requested? *
Are you interested in us quoting for your home, auto, or business insurance? *

YES NO
Best time for us to reach you
How did you hear about us? How much are you currently paying? Who is your current insurance carrier? (If applicable)
Additional Comments / Coverage Requests / Questions
Please UPLOAD - Copy of Drivers License, Survey of Watercraft, and current policy (if applicable)

Cancel of
Which team member assisted you?
Please sign to signify that you have entered all information to the accuracy of your knowledge, and that you agree to the terms and conditions. *

Clear
To access the Terms and Conditions, please CLICK HERE.
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