B Smart Form - Yacht Smart Insurance - Quote Application Form

Yacht Smart

Pleasure craft and yacht insurance application form
Please note that the minimum premium for this product line is currently $10,000. Please contact us if you have any questions regarding this requirement.
Broker Information
Broker Name

First NameLast Name
Broker Email Address
example@example.com
Broker Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Brokerage Name
Insured Information
Application For
Title Insured by:
Titled Insured / Entity
Titled Insured Contact

First NameLast Name
Nationality
Beneficial Owner

First NameLast Name
Beneficial Owner Date of Birth

YearMonthDay
4 digit year, 2 digit month, 2 digit dayDate
Occupation
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Years of Ownership
Years Operating
Prior Vessels Owned
Any Losses
Loss Details

Limits of Coverage
Currency
Hull & Machinery
Tender/Dinghy
Medical Payments
Personal Property
Protection & Indemnity (P&I)
Crew Liability
Uninsured Boaters
Pollution
Certificate of Financial Responsibility (COFR)
CORF: U.S Coast Guard*
COFR Number
Expiry Date

YearMonthDay
4 digit year, 2 digit month, 2 digit dayDate
(*) Oil Pollution Act of 1990 (OPA-90) requires vessels over 300 gross tons to provide a Certificate of
Financial Responsibility (COFR) to the U.S. Coast Guard prior to navigating U.S. waters. Independently of OPA-90, some
States have specific regulations for certain type vessels navigating within their waters, such as the States of Alaska,
California, Oregon, Texas and Washington.

Disclaimer
Have you had any accidents, claims or losses in connection with any vessel you have sailed, owned or was under your control?
Please provide full details, including dates and amounts paid
Have you ever had Insurance declined, non-renewed or cancelled?
Please provide full details
To the best of my knowledge and belief the information provided in connection with this application, whether in my own hand or not, is true and I have not withheld any material facts*.

I understand that non-disclosure or misrepresentation of a material fact* may entitle Underwriters to void the insurance.

*A material fact is one likely to influence acceptance or assessment of this application by underwriters; if you are in any doubt as to whether a fact is material or not you must disclose it.

This application and the information provided in connection therewith contain statements upon which Underwriters will rely in deciding to accept this insurance.

Should a contract of insurance be concluded this application will form the basis of the insurance
Current insurer
Expiry date

YearMonthDay
4 digit year, 2 digit month, 2 digit dayDate
Current Premium
Signature
Confirm Form is Complete
BOS JotForm Submission Key
BOS JotForm Redirection
Should be Empty:

Yacht Smart