Marine Package Application

Marine Package Application

Complete this application for marina operator or boat dealer insurance coverage.
Applicant Information
Applicant Name*
Years in Business*
If less than 3 years in business, please attach resume

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Mailing Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Total Projected Gross Receipts for Term (USD)*
Proposed Effective/Expiration Date*

MonthDayYear
Date
List of Insured Locations (Please list all locations to be insured)*
Deductible Amount $(USD)*
Marine Exposure Receipts (USD)
Dock/Slip Rental
Storage
Fueling
Hauling/Launching
Repair
Rental Boats
Boat Sales
Boat Brokerage Commissions
Retail Store
Restaurant
Liquor Receipts (If Applicable)
Other Receipts (Please Describe)

Premises Protection (Check all that apply for each location)

Rows	Central Station Alarm	Completely fenced & lighted	Watchman service	Owner/Manager lives on premises	Paid fire protection
Location 1
Location 2
Location 3
Location 4

Marina Operator Details

Miles from fire station

Rows	Distance
Location 1
Location 2
Location 3
Location 4

Public fire hydrants (number & distance for each location)

Rows	Number	Distance
Location 1
Location 2
Location 3
Location 4

Other security measures (describe for each location)

Rows	Description
Location 1
Location 2
Location 3
Location 4

Dock and Slip Rental Details

Number of slips and mooring buoys available

Rows	Slips	Mooring Buoys
Location 1
Location 2
Location 3
Location 4

Of the above, how many slips are covered?

Rows	Covered Slips
Location 1
Location 2
Location 3
Location 4

Average value of vessels in slips/moored (USD)

Rows	Average Value
Location 1
Location 2
Location 3
Location 4

Maximum value of vessels in slips/moored (USD)

Rows	Maximum Value
Location 1
Location 2
Location 3
Location 4

Storage Details

Maximum number of vessels stored in one year

Rows	Max Vessels/Year
Location 1
Location 2
Location 3
Location 4

Maximum number stored in summer months

Rows	Summer
Location 1
Location 2
Location 3
Location 4

Maximum number stored in winter months

Rows	Winter
Location 1
Location 2
Location 3
Location 4

Average value of vessels stored (USD)

Rows	Average Value
Location 1
Location 2
Location 3
Location 4

Maximum value of vessels stored (USD)

Rows	Maximum Value
Location 1
Location 2
Location 3
Location 4

Total number of boats stored

Rows	Total Boats
Location 1
Location 2
Location 3
Location 4

Total number of boats stored in racks

Rows	Boats in Racks
Location 1
Location 2
Location 3
Location 4

Maximum number of vessels stored in racks at any one time

Rows	Max in Racks
Location 1
Location 2
Location 3
Location 4

Describe method used to prevent freezing
YesNo
If yes, please upload a copy of the storage agreement

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Describe building(s) construction for land storage
Fueling and Miscellaneous Servicing
EmployeeBoat OwnerOther
YesNo
Fuel tanks: Underground tanks (number)
Underground tanks: Age (years)
Above ground tanks (number)
Above ground tanks: Age (years)
Describe fuel tank maintenance and testing
Hauling and Launching
Describe hauling and launching facilities and equipment
Repair Operations
Type of work performed
YesNo
Highest value of any one vessel (USD)
Maximum values at any one time (USD)
Average values at any one time (USD)
Describe any non-private pleasure vessel work done and amount of gross receipts
Boat Dealers
Please list the following in USD$
Any one watercraft while at a scheduled location
Any one watercraft accepted as trade-in while at locations other than those scheduled for not exceeding 15 days
Any one watercraft during land and water transit within 75 miles of a scheduled location
Any one watercraft while on exhibit at watercraft shows
Any one accident or occurrence with respect to accessories and supplies in inventory at the scheduled locations
Any one accident or occurrence for all coverage provided by this policy, except as provided in the protection and indemnity clause
Any one accident or occurrence, including legal and investigative expenses, with respect to claims covered by the protection and indemnity clause
Boat Dealer Details
Manufacturers and Type of Watercraft
Power (list types) Deep impact, invincible
PWC (Jet Skis, Wave Runners, etc.)
Sail (list types)
Motors (list types)
Trailers (list types)
LandWaterBoth
Maximum delivery distance by land (miles)
Maximum delivery distance by water (miles)
Boat Shows
Number of boat shows annually
Maximum number of boats at any one show
Common carrierOwned vehiclesBoth
Maximum transport distance (miles)
Demonstrations
Number of demonstrations per month
Maximum speed of any one boat demonstrated (mph)
Where are demonstrations performed?
Miles from shore (for demonstrations)
Distance from dealership (for demonstrations, miles)
YesNo
YesNo
YesNo
Hull/Protection & Indemnity

Vessel Name and Description

Rows	Name	Description	Amount Insured
Vessel #1
Vessel #2
Vessel #3
Vessel #4
Vessel #5
Vessel #6
Vessel #7
Vessel #8

Contractors' Equipment
Contractors' Equipment List
Inspection Contact Information
Inspection Contact Name
Inspection Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Inspection Contact Email
example@example.com
Loss Experience (Last 5 Years)
Upload Full Loss Experience Details (if available)

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Loss Experience Table (Last 5 Years)

Rows	Year	Premium	Paid Losses	Open/Settled	Total
Year 1
Year 2
Year 3
Year 4
Year 5

Certification and Signature
Applicant Signature*
Date (Applicant)*

MonthDayYear
Date
Agent or Broker Signature*
Date (Agent or Broker)*

MonthDayYear
Date
ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO CIVIL OR CRIMINAL PENALTIES.
Should be Empty:

Marine Package Application

Applicant Information

Marine Exposure Receipts (USD)

Marina Operator Details

Dock and Slip Rental Details

Storage Details

Fueling and Miscellaneous Servicing

Hauling and Launching

Repair Operations

Boat Dealers

Boat Dealer Details

Manufacturers and Type of Watercraft

Boat Shows

Demonstrations

Hull/Protection & Indemnity

Contractors' Equipment

Inspection Contact Information

Loss Experience (Last 5 Years)

Certification and Signature