Boat Insurance Needs Analysis
Broker Email Address - a copy of the form will be sent to this address
*
example@example.com
Client Reference
*
Date of Enquiry
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Policy Due Date
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Current Insurer
Who referred client?
Sales Team
Insured Details
Insured Name
Date of Birth
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Type of Finance
Geographic Limits
Client Postal Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: 0000000000.
Boating Experience (Years)
Section 1: Boat Details
Hull ** please note: Hull includes sails, masts, spars & rigging
Rows
Details
Year
Make
Model
Const
Rego No.
Serial/VIN No.
Length
HP
Sum Insured
Motor
Rows
Details
Year
Make
Model
Const
Rego No.
Serial/VIN No.
Length
HP
Sum Insured
Motor
Rows
Details
Year
Make
Model
Const
Rego No.
Serial/VIN No.
Length
HP
Sum Insured
Trailer
Rows
Details
Year
Make
Model
Const
Rego No.
Serial/VIN No.
Length
HP
Sum Insured
Boat Name
Stored Location
Surveyed
Please Select
Yes
No
Date of Survey
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
N.C.B
Purchase Price
Purchase Date
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Cover
Please Select
Comprehensive
Third Party
Section 2
Legal Liability
Please Select
$2000000
$5000000
$10000000
$20000000
$30000000
Member of Boating Association
Please Select
Yes
No
Details
Fire Extinguishers
Please Select
None
Manual
Automatic
Fuel
Please Select
Diesel
Petrol
Motor Type
Please Select
Inboard
Outboard
Rear Mount
Mid Mount
Stern Drive
Jet
Type of Use
Please Select
Private
Hire & Charter
Demonstration
Other
Type
Please Select
Runabout
Yacht
Ski Boat
Cruiser
Other
Storage
Please Select
Moored
Garaged
Other
Accessories Equipment
Max. Speed
Boat Licence
Please Select
Yes
No
Expiry Date
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Extensions/Clauses
Please Select
Land Transit Cover
Club Marine Magazine
Racing Risk
Water Skiers
Layup Cover Jan
Layup Cover Feb
Layup Cover March
Layup Cover April
Layup Cover May
Layup Cover Jun
Layup Cover Jul
Layup Cover Aug
Layup Cover Sep
Layup Cover Oct
Layup Cover Nov
Layup Cover Dec
Claims History
For last 5 years (include property damage, theft & fire claims)
Claim #1
Insurer
Date of Loss
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Details of Claim #1
Amount
Claim #2
Insurer
Date of Loss
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Details of Claim #2
Amount
Claim #3
Insurer
Date of Loss
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Details of Claim #3
Duty of Disclosure
Has the Insured or any other owner of the boat:
Rows
Yes or No
Ever had a claim refused or cancelled or declined or special conditions imposed on a boat policy in the last 5 years?
Yes
No
Suffered claims of any nature in the last 5 years?
Yes
No
Been convicted of, or had any fines or penalties imposed for any crime involving drugs, dishonesty, arson, theft, fraud or violence against any person or property in the last 5 years?
Yes
No
Been declared bankrupt and not discharged within the last 12 months?
Yes
No
Is the boat maintained in working order?
Yes
No
Has the boat been modified?
Yes
No
Are there any exceptional circumstances relating to the risk to be insured that you have not already told us about and that you know or should know may affect the Insurer’s decision to accept the insurance?
Yes
No
If Yes, Provide Full Details
Broker Recommendations
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