Name of Assured:
Mailing Address Line 1:
Mailing Address Line 2:
City:
State & Zip:
Survey Contact/Phone:
Type:
If "Other", define:
Producer's Name:
Producer's Address Line 1:
Producer's Address Line 2:
Producer's City:
Producer's State & Zip:
1. List and describe any business owned, operated, or managed by the insured, including any lessor's risk:
2. Number of years in business:
3. Proposed effective date:
4. Please provide name of current carriers, expiring premiums, and policy expiration dates:
5. Is the insured a subsidiary of any other entity or does the insured have any subsidiaries?
If yes, please describe:
6. Any policy or coverage declined, cancelled, or non-renewed during the prior three years? If yes, explain:
Locations:
A.
B.
C.
D.
E.
F.
Coverages Requested
Important Note:
PLEASE COMPLETE APPLICABLE SECTIONS ON THE FOLLOWING PAGES FOR ALL COVERAGES REQUESTED ALSO INCLUDE YES, NO, OR N/A WHERE APPROPRIATE - RECEIPTS AND SALES INFORMATION REQUIRED
Gross Receipts
* Please identify source of other receipts:
Sales
** Please identify source of other sales:
General Information
Protection at locations, Yes or No
Location A:
Describe nature & extent of watchman:
Location B:
Describe nature & extent of watchman:
Location C:
Describe nature & extent of watchman:
Location D:
Describe nature & extent of watchman:
Location E:
Describe nature & extent of watchman:
Location F:
Describe nature & extent of watchman:
Fire Protection
All distances in miles.
Location A:
Paid or Volunteer:
Distance from location(s):
Public fire hydrants - no. and distance:
Public fire mains - size and pressure:
Describe any private fire protection:
Location B:
Paid or Volunteer:
Distance from location(s):
Public fire hydrants - no. and distance:
Public fire mains - size and pressure:
Describe any private fire protection:
Location C:
Paid or Volunteer:
Distance from location(s):
Public fire hydrants - no. and distance:
Public fire mains - size and pressure:
Describe any private fire protection:
Location D:
Paid or Volunteer:
Distance from location(s):
Public fire hydrants - no. and distance:
Public fire mains - size and pressure:
Describe any private fire protection:
Location E:
Paid or Volunteer:
Distance from location(s):
Public fire hydrants - no. and distance:
Public fire mains - size and pressure:
Describe any private fire protection:
Location F:
Paid or Volunteer:
Distance from location(s):
Public fire hydrants - no. and distance:
Public fire mains - size and pressure:
Describe any private fire protection:
Section 1 - Marina Operators Liability
1. Limits requested:
A. Any one vessel
B. Any one accident or occurrence
2. Deductible requested (minimum $1000):
Docking and Mooring
Location A:
Slips available for rent:
Buoys available for rent:
Average value of yachts:
Maximum value of yachts:
Any slips under a common roof:
Location B:
Slips available for rent:
Buoys available for rent:
Average value of yachts:
Maximum value of yachts:
Any slips under a common roof:
Location C:
Slips available for rent:
Buoys available for rent:
Average value of yachts:
Maximum value of yachts:
Any slips under a common roof:
Location D:
Slips available for rent:
Buoys available for rent:
Average value of yachts:
Maximum value of yachts:
Any slips under a common roof:
Location E:
Slips available for rent:
Buoys available for rent:
Average value of yachts:
Maximum value of yachts:
Any slips under a common roof:
Location F:
Slips available for rent:
Buoys available for rent:
Average value of yachts:
Maximum value of yachts:
Any slips under a common roof:
Describe type of heavy lift equipment and indicate lifting capacity:
Storage*
Location A:
Max number of yachts stored at any time in past year:
Number stored in summer:
Number stored in winter:
Average value of yachts:
Max value of yachts:
Location B:
Max number of yachts stored at any time in past year:
Number stored in summer:
Number stored in winter:
Average value of yachts:
Max value of yachts:
Location C:
Max number of yachts stored at any time in past year:
Number stored in summer:
Number stored in winter:
Average value of yachts:
Max value of yachts:
Location D:
Max number of yachts stored at any time in past year:
Number stored in summer:
Number stored in winter:
Average value of yachts:
Max value of yachts:
Location E:
Max number of yachts stored at any time in past year:
Number stored in summer:
Number stored in winter:
Average value of yachts:
Max value of yachts:
Location F:
Max number of yachts stored at any time in past year:
Number stored in summer:
Number stored in winter:
Average value of yachts:
Max value of yachts:
A. Are yachts stored afloat between 12/1 and 4/1?
B. Are yachts stored inside a building?
If yes, are they on racks?
Is there a Sprinkler System?
C. Type of building construction:
D. Fire rate:
E. Are yachts stored outside on racks?
If yes, how many?
* If you provide any storage, a copy of the storage agreement is required for coverage to apply.
Repair Operations
A. Type of vessels:
B. Type of work:
C. Highest value of any one yacht repaired last year:
D. Describe any commercial ship repair work you do and provide receipts:
E. Receipts (non-commercial) past 12 months:
Section 2 - Protection and Indemnity
Sections Applicable:
Marina Operators:
Boat Dealers:
Work Boats:
Number of Work Boats:
Rental Boats:
Number of Rental Boats:
Other Owned Boats (excl. Boats for Sale):
Number of "Other Owned Boats":
For work boats, rental boats and other owned boats,
indicate make, year built, length and horsepower for each:
Limit Requested:
For each watercraft, are crew covered?
If "yes" was selected, list no.:
Please fully describe work boat / rental boat / other owned boat operation
if you are requesting P&I coverage for these vessels:
Section 3 - General Liability
|
Limits Requested (choose one)
|
Option A:
|
Option B:
|
Option C:
|
|
A. General Aggregate
|
$2,000,000
|
$1,000,000
|
$1,000,000
|
|
B. Products-Completed Ops Aggregate
|
$1,000,000
|
$500,000
|
$300,000
|
|
C. Personal And Advertising Injury
|
$1,000,000
|
$500,000
|
$300,000
|
|
D. Each Occurrence
|
$1,000,000
|
$500,000
|
$300,000
|
|
E. Fire Damage (Any One Fire)
|
$100,000
|
$100,000
|
$100,000
|
|
F. Medical Expense (Any One Person)
|
$5,000
|
$5,000
|
$5,000
|
Products Sold (ex. boats & ship stores)
Product 1
Type:
Annual Sales:
no. Of Units:
Intended Use:
Product 2
Type:
Annual Sales:
no. Of Units:
Intended Use:
Product 3
Type:
Annual Sales:
no. Of Units:
Intended Use:
Product 4
Type:
Annual Sales:
no. Of Units:
Intended Use:
For the following, Explain all "Yes" responses
1. Does applicant install, service, or demonstrate products?
Explain:
2. Foreign products sold, distributed, used as components?
Explain:
3. Research and development conducted or new products planned?
Explain:
4. Guarantees, warranties, hold harmless agreements?
Explain:
5. Products recalled, discontinued, changed?
Explain:
6. Products of others sold or repackaged under applicant's label?
Explain:
7. Products under label of others?
Explain:
8. Vendors coverage required?
Explain:
9. Does any named insured sell to other named insured?
Explain:
10. Products manufactured? YesNoN/A
Explain:
Please attach literature, brochures, labels, warnings, etc.
Additional interests/certificate recipients?
Recipient 1
Name and address:
Interest:
Certificate:
Recipient 2
Name and address:
Interest:
Certificate:
Recipient 3
Name and address:
Interest:
Certificate:
General Information
For the following, Explain all "Yes" responses
1. Any medical facilities provided or doctor employed/contracted?
Explain:
2. Any exposure to radioactive/nuclear material?
Explain:
3. Do operations involve storing, treating, discharging, applying, disposing, or transporting of hazardous material?
Explain:
4. Any operations sold, acquired or discontinued in last 5 years? YesNoN/A
Explain:
5. Any parking facilities owned/operators?
Number of parking spaces:
Explain:
6. Is a fee charged for parking?
Explain:
7. Recreation facilities provided?
Explain:
8. Is there a swimming pool on the premises?
Explain:
9. Sporting or social events sponsored?
Explain:
10. Any structural alterations contemplated?
Explain:
11. Any demolition exposure contemplated?
Explain:
12. Does harbormaster or any other person(s) live on premises?
Explain:
Additional Remarks:
Section 4 - Boat Dealer's Insurance
Requested Limits:
A. Limit any one vessel:
B. Limit any one location:
C. Limit any one accident or occurrence:
D. Deductible each occurrence each location:
Type of boats sold and manufacturer:
Are any High Performance Boats Sold?
Are any Personal Watercraft or Jet Ski's Sold?
Are any Snowmobiles Sold?
In the following: * - Should be six months from prior inventory date.
Date for 'Last Inventory Date' column:
Date for 'Prior Inventory* Date' column:
Last and Prior inventory date correspond to the ones input directly above.
Transit Exposures:
A. Are any boats delivered from mfr. at Insured's risk?
If "Yes", how are they delivered?
Max. value any one boat:
Max. value any one delivery:
B. Are any boats delivered by water to the insured?
If "Yes", from where?
C. Total values of boats delivered by insured during the past year:
D. By public carrier:
E. By applicant's vehicle:
F. Average distance the boats are transported:
Maximum distance boats transported:
G. Number of boats delivered to purchaser by water:
H. Average distance:
Average value:
Boat Shows
No. of boat shows annually:
No. of boats each show:
In water or on land:
Maximum dollar limit any one show:
Average/maximum distance to show:
Transported by common carrier or own vehicles?
Demonstrations
Maximum value any one boat:
Maximum mph any one boat:
Is boat under command of competent employee?
Are demonstrators equipped with full complement of U.S. Coast Guard required safety equipment? YesNoN/A
Section 5 - Piers Wharves And Docks
Indicate Valuation: Choose One
General
Location A:
Number of floating docks:
Number of fixed piers:
Insured value for docks:
Insured value for piers:
Location B:
Number of floating docks:
Number of fixed piers:
Insured value for docks:
Insured value for piers:
Location C:
Number of floating docks:
Number of fixed piers:
Insured value for docks:
Insured value for piers:
Location D:
Number of floating docks:
Number of fixed piers:
Insured value for docks:
Insured value for piers:
Location E:
Number of floating docks:
Number of fixed piers:
Insured value for docks:
Insured value for piers:
Location F:
Number of floating docks:
Number of fixed piers:
Insured value for docks:
Insured value for piers:
Attach a diagram of the docks/piers if available.
Describe the floating docks and piers:
Indicate type of construction:
Indicate type of flotation devices:
Indicate type of mooring devices:
Age of docks:
Age of piers:
Are the slips open or covered?
Number of open slips:
Number of covered slips:
Describe the maintenance program:
Describe firefighting capabilities:
Deductible Requested ($1,000 Minimum):
Section 6 - Property Insurance
Premises Information
Location No:
Building No:
Building
Subject of Insurance:
ACV (ACV 80%)Repl Cost (RC 90%)
Limit:
Contents
Subject of Insurance:
ACV (ACV 80%)Repl Cost (RC 90%)
Limit:
Other
Subject of Insurance:
ACV (ACV 80%)Repl Cost (RC 90%)
Limit:
Deductible, (minimum $500):
Year built:
How is this building used by the Insured?
Construction type:
Protection class:
RCP Code:
Total area:
Other occupancies:
Building improvements:
Wiring, yr.:
Plumbing, yr.:
No. of stories:
Burglar Alarm:
Describe:
Sprinkler Alarm:
Describe:
Basement:
Business Income and Extra Expense Coverage - Actual Loss Sustained Requested Limit (Coinsurance 80%):
Premises Information
Location No:
Building No:
Building
Subject of Insurance:
Limit:
Contents
Subject of Insurance:
Limit:
Other
Subject of Insurance:
Limit:
Deductible, (minimum $500):
Year built:
How is this building used by the Insured?
Construction type:
Protection class:
RCP Code:
Total area:
Other occupancies:
Building improvements:
Wiring, yr.:
Plumbing, yr.:
No. of stories:
Burglar Alarm:
Describe:
Sprinkler Alarm:
Describe:
Basement:
Business Income and Extra Expense Coverage - Actual Loss Sustained Requested Limit (Coinsurance 80%):
Premises Information
Location No:
Building No:
Building
Subject of Insurance:
Limit:
Contents
Subject of Insurance:
Limit:
Other
Subject of Insurance:
Limit:
Deductible, (minimum $500):
Year built:
How is this building used by the Insured?
Construction type:
Protection class:
RCP Code:
Total area:
Other occupancies:
Building improvements:
Wiring, yr.:
Plumbing, yr.:
No. of stories:
Burglar Alarm:
Describe:
Sprinkler Alarm:
Describe:
Basement:
Business Income and Extra Expense Coverage - Actual Loss Sustained Requested Limit (Coinsurance 80%):
Section 7 - Equipment/Tools
Equipment Coverage, Indicate Valuation, Choose One
Complete the following or submit schedule:
Equipment 1
Description:
Value:
D/A:
Serial Number:
Location:
Equipment 2
Description:
Value:
D/A:
Serial Number:
Location:
Equipment 3
Description:
Value:
D/A:
Serial Number:
Location:
Equipment 4
Description:
Value:
D/A:
Serial Number:
Location:
Equipment 5
Description:
Value:
D/A:
Serial Number:
Location:
Section 8 - Owned Watercraft
Owned Watercraft Coverage, Indicate Valuation, Choose One
Fully describe any operation for which you are requesting coverage for owned watercraft:
Complete the following or submit schedule:
Watercraft 1
Description:
Value:
D/A:
Serial Number:
Location:
Watercraft 2
Description:
Value:
D/A:
Serial Number:
Location:
Watercraft 3
Description:
Value:
D/A:
Serial Number:
Location:
Watercraft 4
Description:
Value:
D/A:
Serial Number:
Location:
Watercraft 5
Description:
Value:
D/A:
Serial Number:
Location:
If you are requesting coverage for boats that are rented please submit a copy of the applicable rental agreement as well as a description of your rental qualification standards.
Morgagees/Loss Payees
Name and Address:
Interest:
Coverage Section(s) Applicable:
Location:
Name and Address:
Interest:
Coverage Section(s) Applicable:
Location:
Name and Address:
Interest:
Coverage Section(s) Applicable:
Location:
Name and Address:
Interest:
Coverage Section(s) Applicable:
Location:
Name and Address:
Interest:
Coverage Section(s) Applicable:
Location:
Name and Address:
Interest:
Coverage Section(s) Applicable:
Location:
Name and Address:
Interest:
Coverage Section(s) Applicable:
Location:
Name and Address:
Interest:
Coverage Section(s) Applicable:
Location:
Please attach any additional files here
FOR ALL SECTIONS
Loss Record
List all claims incurred during the past five years to property or from operations covered by this form of policy including date, cause, amount paid or estimated amount, if claim not settled. If none, state "none".
Important Note
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION OF INSURANCE CONTAINING ANY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME.
Signature of Applicant:
Date:
