Submitter First Name What is your first name?
Submitter Last Name What is your last name?
Submitter Email What is your email?
Submitter Phone Number What is your phone number?
Ownership Information Ultimate Beneficial Owner? Who is/are the ultimate beneficial owner(s) of this yacht?
Submitter Date of Birth What is your date of birth?
MM slash DD slash YYYY
Submitter Address What is your primary home address?
Beneficial Owner Home Status Is this residence owned or rented?
Beneficial Owner 2 Full Name What is the co-owner's full name?
Beneficial Owner 2 Occupation What is the co-owner's occupation?
Beneficial Owner 2 Employer What is the name of the co-owner's employer?
Beneficial Owner 2 Date of Birth What is the co-owner's date of birth?
MM slash DD slash YYYY
Relationship to Beneficial Owner 2 What is your relationship to the co-owner?
Married Domestic Partner Engaged Family Member (Brother, Sister, Father, Mother, etc.) Cohabitants / Life Partners Other
Relationship Description with Beneficial Owner 2 Please describe your relationship with them.
Sole Beneficial Owner Full Name What is the ultimate beneficial owner's full name?
Sole Beneficial Owner Occupation What is the ultimate beneficial owner's occupation?
Sole Beneficial Owner Employer What is the name of the ultimate beneficial owner's employer?
Sole Beneficial Owner Date of Birth What is the ultimate beneficial owner's date of birth?
MM slash DD slash YYYY
Sole Beneficial Owner Address What is the primary home address for the ultimate beneficial owner?
Sole Beneficial Owner Home Status Is this residence owned or rented?
Sole Beneficial Owner Marital Status What is the ultimate beneficial owner's marital status?
Single Married Divorced Widowed
Multiple Beneficial Owners List Please enter information about the beneficial owners of this yacht below.
Submitter Relationship to Beneficial Owners What is your relationship to the beneficial owner(s)?
Employer/Employee Family Office Yacht Management Company Other
Submitter Relationship Description with Beneficial Owners Please describe your relationship with them.
Address for Lead Beneficial Owner Please provide the primary home address for one of the beneficial owners.
Lead Beneficial Owner Home Status Is this residence owned or rented?
Corporately Titled? Is the yacht titled in the name of a corporation?
Title Corporation Name What is the name of the corporation?
Corporation Purpose Was this corporation established for the sole purpose owning this yacht?
Corporation Purpose Description Please provide a brief explanation of the other purpose(s) for which this corporation exists.
Driver Information Yacht Driver? Who will drive the yacht?
Submitter Driver License Number What is your drivers license number?
Submitter License State Which state are you licensed in?
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Armed Forces Americas Armed Forces Europe Armed Forces Pacific Other
Submitter License State/Country Other What state/country are you licensed in?
Submitter Accidents Violations Has you had any accidents or violations within the last four years? (Please check all that apply)
Submitter Accident Type 1 What type of accident was it?
Submitter Accident 1 Description Please provide a brief description of the accident.
Submitter Accident 1 Date What date did this accident occur?
MM slash DD slash YYYY
Submitter Accident 2? Is there a second accident for this driver?
Submitter Accident Type 2 What type of accident was it?
Submitter Accident 2 Description Please provide a brief description of the second accident.
Submitter Accident 2 Date What date did the second accident occur?
MM slash DD slash YYYY
Submitter Violation Type 1 What type of violation did this driver have?
Submitter Violation 1 Description Please provide a brief description of the situation that resulted in the violation.
Submitter Violation 1 Date What date did this violation occur?
MM slash DD slash YYYY
Submitter Violation 2? Is there a second violation for this driver?
Submitter Violation Type 2 What type of violation was it?
Submitter Violation 2 Description Please provide a brief description of the second violation.
Submitter Violation 2 Date What date did the second violation occur?
MM slash DD slash YYYY
Yacht Driver #2 Is there another driver?
Yacht Driver #2 Full Name Please enter their full name exactly as it appears on their license.
Yacht Driver #2 License Number What is this driver's license number?
Yacht Driver #2 License State Which state is this driver licensed in?
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Armed Forces Americas Armed Forces Europe Armed Forces Pacific Other
Yacht Driver License State/Country Other What state/country are you licensed in?
Yacht Driver #2 Date of Birth What is this driver's date of birth?
MM slash DD slash YYYY
Co-Owner Accidents Violations Has this driver had any accidents or violations within the last four years? (Please check all that apply)
Co-owner Accident Type 1 What type of accident was it?
Co-owner Accident 1 Description Please provide a brief description of the accident.
Co-owner Accident 1 Date What date did this accident occur?
MM slash DD slash YYYY
Co-owner Accident 2? Is there a second accident for this driver?
Co-owner Accident Type 2 What type of accident was it?
Co-owner Accident 2 Description Please provide a brief description of the second accident.
Co-owner Accident 2 Date What date did the second accident occur?
MM slash DD slash YYYY
Co-owner Violation Type 1 What type of violation did this driver have?
Co-owner Violation 1 Description Please provide a brief description of the situation that resulted in the violation.
Co-owner Violation 1 Date What date did this violation occur?
MM slash DD slash YYYY
Co-owner Violation 2? Is there a second violation for this driver?
Co-owner Violation Type 2 What type of violation was it?
Co-owner Violation 2 Description Please provide a brief description of the second violation.
Co-owner Violation 2 Date What date did the second violation occur?
MM slash DD slash YYYY
Helmsman Full Name Please enter the helmsman's full name.
Helmsman Drivers License Number Please enter the helmsman's drivers license number.
Helmsman License State Which state is the helmsman licensed in?
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Armed Forces Americas Armed Forces Europe Armed Forces Pacific Other
Helmsman License State/Country Other Please enter where the helmsman licensed?
Helmsman Date of Birth What is the helmsman's date of birth?
MM slash DD slash YYYY
Helmsman Accidents Violations Has this driver had any accidents or violations within the last four years? (Please check all that apply)
Helmsman Accident Type 1 What type of accident was it?
Helmsman Accident 1 Description Please provide a brief description of the accident.
Helmsman Accident 1 Date What date did this accident occur?
MM slash DD slash YYYY
Helmsman Accident 2? Is there a second accident for this driver?
Helmsman Accident Type 2 What type of accident was it?
Helmsman Accident 2 Description Please provide a brief description of the second accident.
Helmsman Accident 2 Date What date did the second accident occur?
MM slash DD slash YYYY
Helmsman Violation Type 1 What type of violation did this driver have?
Helmsman Violation 1 Description Please provide a brief description of the situation that resulted in the violation.
Helmsman Violation 1 Date What date did this violation occur?
MM slash DD slash YYYY
Helmsman Violation 2? Is there a second violation for this driver?
Helmsman Violation Type 2 What type of violation was it?
Helmsman Violation 2 Description Please provide a brief description of the second violation.
Helmsman Violation 2 Date What date did the second violation occur?
MM slash DD slash YYYY
Captain Full Name Please enter the captain's full name.
Captain Drivers License Number Please enter the captain's drivers license number.
Captain License State Which state is the captain licensed in?
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Armed Forces Americas Armed Forces Europe Armed Forces Pacific Other
Captain License State/Country Other Please enter where the captain licensed?
Captain Date of Birth What is the captain's date of birth?
MM slash DD slash YYYY
Captain Accidents Violations Has this driver had any accidents or violations within the last four years? (Please check all that apply)
Captain Accident Type 1 What type of accident was it?
Captain Accident 1 Description Please provide a brief description of the accident.
Captain Accident 1 Date What date did this accident occur?
MM slash DD slash YYYY
Captain Accident 2? Is there a second accident for this driver?
Captain Accident Type 2 What type of accident was it?
Captain Accident 2 Description Please provide a brief description of the second accident.
Captain Accident 2 Date What date did the second accident occur?
MM slash DD slash YYYY
Captain Violation Type 1 What type of violation did this driver have?
Captain Violation 1 Description Please provide a brief description of the situation that resulted in the violation.
Captain Violation 1 Date What date did this violation occur?
MM slash DD slash YYYY
Captain Violation 2? Is there a second violation for this driver?
Captain Violation Type 2 What type of violation was it?
Captain Violation 2 Description Please provide a brief description of the second violation.
Captain Violation 2 Date What date did the second violation occur?
MM slash DD slash YYYY
Boating History & Experience Owner Years Experience How many years of boating experience does the owner have?
Boats/yachts owned or rented Please select the applicable option(s) below.
Previous Vessels Owned Please provide the following information about previous vessels owned.
Previous Vessels Rented Please provide the following information about previous vessels rented/borrowed.
Boating Courses? Has the owner(s) taken any boating courses?
Boating Course Selection Please select the course(s) the owner has taken.
Boating Course Other Please enter the other boating course(s) the owner has taken.
Helmsman's Experience Helmsman Years Experience How many years of boating experience does the helmsman have?
Helmsman Previous Vessels Operated Please provide the following information about vessels the helmsman previously piloted.
Helmsman Boating Course Selection Please select the course(s) the helmsman has taken.
Helmsman Boating Course Other Please enter the other boating course(s) the helmsman has taken.
Captain's Experience Captain Years Experience How many years of boating experience does the captain have?
Captain Previous Vessels Operated Please provide the following information about vessels the captain previously operated.
Captain Boating Course Selection Please select the course(s) the captain has taken.
Captain Boating Course Other Please enter the other boating course(s) the captain has taken.
Yacht Information New Yacht Purchase? Is this yacht a new purchase?
Yacht Purchase Price What is the purchase price?
What is the purchase/transaction date? What is the purchase/transaction date?
MM slash DD slash YYYY
What is the delivery/pick up date? What is the delivery/pick up date?
MM slash DD slash YYYY
What was the purchase/transaction date? What was the purchase/transaction date?
MM slash DD slash YYYY
What is the yacht's flag state? What is the yacht's flag state?
New Purchase Yacht Financing? Will this yacht purchase be financed?
Yacht Existing Coverage? Is there an insurance policy currently in place for this yacht?
Current Insurance Company Name What is the name of the current insurance company?
Current Insurance Deductible What is the current insurance deductible?
Current Insurance Premium What is the current insurance premium?
Yacht Current Value What is the current value of the yacht?
Yacht Effective Date What date would you like coverage to commence?
MM slash DD slash YYYY
Existing Yacht Financing Is there a lien on this yacht?
Lending Institution/Bank Name? What is the name of the lending institution/bank providing the financing?
Lending Institution/Bank Address What is the address of the lending institution/bank?
Loan Number? What is the loan number?
Yacht Name What is the yacht's name?
Yacht Model Year? What is the yacht's model year?
Yacht Renovation? Has the yacht been renovated?
Yacht Renovation Year What year was the yacht renovated?
Yacht Renovation Description Please provide a brief overview of the renovation.
Yacht Builder/Manufacturer What is the name of the yacht's builder/manufacturer?
Yacht Model What is the yacht's model?
Yacht Length? What is the length of the yacht?
Yacht Gross Tonnage What is the gross tonnage of the yacht?
Yacht Superstructure Material? What is the yacht's superstructure material?
Fiberglass Aluminum Wood Steel Other
Yacht Superstructure Material Other What material was used for the construction of the yacht's superstructure?
Yacht Hull Material? What is the yacht's hull material?
Fiberglass Aluminum Wood Steel Other
Yacht Hull Material Other What material was used for the construction of the yacht's hull?
Hull ID Number? What is the hull ID number/serial number (HIN)?
Condition and Valuation Survey? Is there a recent condition and valuation survey available?
Condition and Valuation Survey Upload Please upload a copy of the condition and valuation survey, if available.
Yacht Hull Type? What type of hull does this yacht have?
Runabout Cruiser Sportfisher Mono Hull Sailboat Multi Hull Sailboat Trawler Houseboat Bass Boat Inflatable Other
Yacht Hull Type Other Please enter the hull type of this yacht?
Number of Engines? How many engines does this yacht have?
1 2 3 4
Yacht Fuel Type What type of fuel does this yacht run on?
Gasoline Diesel Electricity Other
Yacht Fuel Type Other Please enter the type of fuel this yacht runs on?
Yacht Engine Type What type of engine(s) does this yacht have?
Outboard Inboard Inboard/Outboard Drive Pods Wartsilla Hybrid Technology Power Plants MTU Engines 2-Cycle Detroit Diesel Other
Yacht Engine Type Other Please enter the type of engine that powers this yacht.
Engine Year What is the engine year?
Engine Manufacturer Name What is the name of the engine manufacturer?
Engine Serial Number(s) Please enter the engine serial number(s).
Total Engine Horsepower What is the total horsepower?
Yacht Top Speed What is this yacht's top speed?
Additional Equipment Onboard Pleas select the additional equipment onboard this yacht.
Additional Equipment Onboard Other Please enter any other additional equipment onboard this yacht.
Salvage Purchase? Was this yacht purchased as salvage or have any existing or prior damage?
Previous Yacht Claims? Have there been any previous yacht/boat insurance claims?
Prior boat insurance claims history? Please enter information about any yacht/boat insurance claims below.
Navigation, Usage & Mooring Navigation Area Please select the yacht's navigation area.
US East Coast & Bahamas US East Coast & Bahamas - Warranted North of FL from 06/30-11/01 US East Coast & Bahamas - Warranted North of Cape Hatteras from 06/01-11/15 US East Coast - North of FL - Year Round US East Coast - North of Moorehead City - Year Round US East Coast & Bahamas - North of FL/GA Line from 06/01-11/01 Chesapeake Bay Only Gulf Coastal Waters Inland Lakes & Rivers - Excluding Great Lakes Inland Lakes & Rivers - Including Great Lakes Great Loop US West Coast Caribbean East Coast - Central America West Coast - Central America Other
Navigation Area Other Please describe the desired navigation area.
Secondary Navigation Area? Is a secondary navigation area required?
Secondary Navigation Area Description Please provide a description of the secondary navigation area.
Yacht Usage? How will the yacht be used?
Pleasure Commercial Passenger Charter Other
Yacht Usage Other Please describe how this yacht will be used.
Number of Charters How many passenger charters will this yacht do annually?
Charter Types Please select the type(s) of charter(s) this yacht will do.
Charter Type Other Please provide a brief description of the type of charter this yacht will do.
Commercial Use Description Please describe the commercial use.
Racing? Will this yacht be used for racing?
Living Onboard? Will anyone be living onboard this yacht?
How will the yacht be delivered to the mooring location? How will the yacht be delivered to the mooring location?
Summer Marina Name? What is the name of the marina/facility where the yacht is moored in the summer?
Summer Location Type What type of location is the summer marina/facility?
Dock Mooring Buoy Trailered Lift Rack/Valet Storage Stands Other
Summer Location Type Other How will the yacht be moored at this marina/facility in the summer?
Summer Mooring Location Address Please enter the address where the yacht is kept in the summer.
Winter Mooring Different? Is the winter mooring location different than the summer location?
Winter Marina Name? What is the name of the marina/facility where the yacht is moored in the winter?
Winter Mooring Location What is the address where the yacht is moored in the winter?
Winter Location Type What type of location is the winter marina/facility?
Dock Mooring Buoy Trailered Lift Rack/Valet Storage Stands Other
Winter Location Type Other How will the yacht be moored at this marina/facility in the winter?
Lay-up Out of Commission? Does this yacht lay-up out of commission?
Lay-up Period Start When does the lay-up period start?
MM slash DD slash YYYY
Lay-up Period End When does the lay-up period end?
MM slash DD slash YYYY
Lay-up Ashore/Afloat? How is the yacht stored during the lay-up period?
Lay-up Conditions Please select the conditions that apply to this yacht while it is laid-up.
Where is the yacht located right now? Where is the yacht located right now?
Held for Sale? Is the yacht currently held for sale?
Crew Paid Crew? Is there a paid crew?
Number of Full Time Crew How many full-time crew members are there?
Number of Part Time Crew How many part-time crew members are there?
Crew Nationalities? Please list the nationalities of the crew members.
Combined Monthly Payroll What is the combined monthly payroll for all crew members?
Captain's Salary What is the captain's annual salary?
Crew Claims? Have there been any previous claims for the crew?
Crew Claim Details Please provide details on the claims for the crew member(s).
Tenders, Toys and Fine Art Onboard Tender Onboard? Is there a tender onboard this yacht?
Tender Make, Length, Engine Make, Horsepower Please provide the requested details about the tender.
Tender Value with Engine What is the value of the tender, including the engine?
Tender Transportation? Please describe how the tender is being transported.
Trailer? Is there a trailer?
Trailer Details and Value Please provide details on the trailer and its value.
Toys Onboard? Will there be any toys kept onboard this yacht? (Ex. Jet skis)
Toy Types Onboard Please select the toys that will be kept onboard this yacht.
Toys Onboard Other What are the other types of toys that will be kept on this yacht?
Toys Value What is the total value of all the toys kept on this yacht?
Fine Art Onboard? Is there fine art onboard this yacht?
Fine Art Value What is the value of the fine art onboard this yacht?
Documents and Comments Document upload Please use this field to upload any relevant insurance documents. (I.e. Current policy declarations pages, etc...)
Remarks Please enter any additional remarks in the space below.
<font size="2" color="gray">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.* 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.
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