Custom Lines Boat/Yacht Insurance Application

Custom Lines Insurance Brokerage Application
Purchase Date*

MonthDayYear
Date
Titled Owner of Vessel or LLC*
Address*
City*
State*
Zip*
Drivers License #*
Driver License State*
Beneficial Owner's Name(s)*
Date of Birth(s)*

MonthDayYear
Date
Primary Owner’s Telephone*
Occupation(s)
Primary Owner’s Email*
example@example.com
If Florida, does Insured reside there 12 months of the year? (Yes/No)?*
Total years of Boat ownership*
Length and Manufacturer of previously boats owned
Year Length Make Model
LOSS INFORMATION:
Does the insured have any previous loss history (Yes/No)*
Any claims in the past 5 years
YACHT TO BE INSURED
Year*
Length*
Manufacturer*
Model*
Hull #
Purchase Amount*
Vessel Name
Engine Manufacturer*
Engine Model*
Number of Engines*
Total Horsepower*
Max Speed*
Satellite-based, Theft Deterrent GPS w/Tracking Capability* REQUIRED
Make
Model
*(If GPS system is required by Insurance Company, it must be activated and in service 24/7)
Has a survey been performed or scheduled
Survey Date

MonthDayYear
Date
Surveyor
TRAILER
Trailer Year
Manufacturer
Trailer Serial #
Value
Non Hurricane Season

December to May
Location Name*
Address*
City*
State*
Zip*
Type of Mooring*
Lift, Afloat, Rack, Inside Barn, Trailer or Other
Hurricane Season

June 1 to November 30
Location Name*
Address*
City*
State*
Zip*
Type of Mooring*
Lift, Afloat, Rack, Inside Barn, Trailer or Other
LOSS PAYEE / BANK / LIENHOLDER:
Name
Address

Street Address Line 2

CityState

Zip
Additional Insured

Marina
Name
City
Address

Address

Street Address Line 2

CityState

Zip
I declare that the answers above are true to the best of my knowledge and that all material facts related to the risk to be insured have been disclosed. I also agree that the information given herein shall form the basis upon which the insurance will be offered, as well as the basis for the insurance contract between me and the insurer if a policy is subsequently issued. Non-disclosure or misrepresentation of any material fact related to the risk may result in the withdrawal of the offer and / or the nullification of the insurance policy.
Insured’s Signature*

Clear
Date

MonthDayYear
Date
Should be Empty:

LOSS INFORMATION:

YACHT TO BE INSURED

Non Hurricane Season

Hurricane Season

LOSS PAYEE / BANK / LIENHOLDER:

Additional Insured