Watercraft Severe Storm Statement Form

What is your first name?

What is your last name?

What is your preferred phone number?

Email

Please enter your email.

Emergency Contact

Is there another person, besides the owner, who should be listed as an emergency contact for this vessel?

Yes
No

Emergency Contact Name

What is the name of the person we should contact in the event of an emergency with your vessel?

Emergency Contact Relationship to Owner Details

What is the emergency contact's relationship to the owner?

Emergency Contact Phone

What is the emergency contact's phone number?

Emergency Contact Email

What is the emergency contact's email address?

Vessel Name

What is the name of the vessel?

Vessel Location June 1 to November 30

Where will the vessel be located from June 1st to November 30th?

Private Residence
Marina

Residence Owner?

Who is the owner of the private residence?

Residence address

What is the complete address of the residence where the vessel will be located?

Street Address Address Line 2 City State ZIP Code

Name of Marina?

What is the name of the marina?

Marina address

What is the complete address of the marina where the vessel will be located?

Street Address Address Line 2 City State ZIP Code

Security Details

Please select the applicable security measures that are in place for this watercraft. (Select all that apply)

Full Lighting
Gated
24-hour Manned Security
Pre-cast Concrete Pilings
Motion Sensor and/or Video Surveillance

GPS Tracking?

Does this vessel have GPS tracking capabilities installed?

Yes
No

GPS Tracker Make

What is the GPS tracker manufacturer's name?

GPS Tracker Model

What is the GPS tracker model?

GPS Satellite?

Is the GPS tracker a satellite based system?

Yes
No

GPS Tracker Agreement

Do you agree to keep the GPS tracker in working order and the monthly service active?

Yes
No

Frequency of Visits

How frequently do you visit the vessel?

Daily
Weekly
Monthly

Additional Vessel Attendee

Who attends to the vessel when you do not or are unable to?

Attendee Relationship to Owner

What is the back up attendee's relationship to you / the owner?

Back Up Attendee Phone

What is the back up attendee's phone number?

Back Up Attendee Email

What is the back up attendee's email address?

Back Up Attendee Visit Frequency

How often does the back up attendee visit the vessel?

Daily
Weekly
Monthly

Back Up Attendee Paid?

Is the back up attendee paid?

Yes
No

Crew Coverage?

Do you want / require coverage for a crew?

Yes
No
Already Have Crew Coverage

Storm Preparedness Plan

Please give full details of your plan for protecting the vessel in the event of any storm warning, including intended places of refuge, mooring and/or anchoring arrangements and how the vessel will be secured.

Equipment Stowed?

Will your Bimini top, canvas, antennas and outriggers be stowed correctly from wind exposure?

Yes
No

Additional Precautions?

Will you be using additional anchors, chafe gear, and multiple mooring lines?

Yes
No

Neighboring Boats Contact

Are you in contact with your neighboring boaters to be sure that unattended boats are properly secured?

Yes
No

Back Up Plan?

Do you have any alternative plans in the event that the primary plan cannot be executed for some reason?

Yes
No

Back Up Plan Details?

Please provide details of your back up plan.

Vessel Stored Ashore?

Will your vessel be kept ashore during a storm (including on a trailer or lift)?

Yes
No

Securing Vessel Details

Please provide details on how the vessel will be secured ashore.

Storm Experience

Have you ever had to prepare for a hurricane, cyclone, or typhoon before?

Yes
No

Storm Experience Tips

Please share any tips or comments you can from your prior experience. We appreciate it!

Severe Storm Statement

IT IS HEREBY UNDERSTOOD AND AGREED that in the event of a named hurricane, cyclone or typhoon warning, I/we will make every reasonable effort to secure our vessel in a suitable shelter, slip or mooring and take all other reasonable precautions that may be necessary to safeguard the vessel and/or its equipment and accoutrements, including, but not limited to: removing/stowing of Bimini top canvas, loose cushions, roller-furled sails, outriggers and antennas. The undersigned/assured is aware that, in the event of physical damage to the insured vessel, the assured is responsible for payment of the deductible amount shown on the Declarations Page and/or as superseded by the Policy or as otherwise stated by Endorsement to the Policy).

Insured Full Name

Please print your full name

Today's Date

Please enter today's date.

Hurricane Preparedness Plan Signature

Please sign your name in the space below.

Consent*

Disclaimer: This online questionnaire is a tool used to gather information. It is not an application for insurance. No insurance coverage will be bound or put into effect by submitting this form.

Consumer disclosure: By checking the box below you authorize the Agency who supplied this form to you to contact you via phone, email, and text messaging; to save and share with business partners the information you provided; to obtain consumer reports that may include credit-based reports (where legally allowed), public records, claims history, and driving records so that they can give you accurate insurance quotes.

I agree

Watercraft Severe Storm Statement Form

Storm Preparedness Plan

Severe Storm Statement

AJG (Ericson) Service

RiskRevu^TM Newsletter

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Watercraft Severe Storm Statement Form

Storm Preparedness Plan

Severe Storm Statement

AJG (Ericson) Service

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RiskRevuTM Newsletter

Contact

RiskRevu^TM Newsletter