What is your first name?
What is your last name?
What is your email?
What is your occupation?
What is the name of your employer?
What is your phone number?
Ownership Information
Who is/are the ultimate beneficial owner(s) of this yacht?
What is your date of birth?
MM slash DD slash YYYY
What is your primary home address?
Is this residence owned or rented?
What is the co-owner's full name?
What is the co-owner's occupation?
What is the name of the co-owner's employer?
What is the co-owner's date of birth?
MM slash DD slash YYYY
What is your relationship to the co-owner?
Please describe your relationship with them.
What is the ultimate beneficial owner's full name?
What is the ultimate beneficial owner's occupation?
What is the name of the ultimate beneficial owner's employer?
What is the ultimate beneficial owner's date of birth?
MM slash DD slash YYYY
What is the primary home address for the ultimate beneficial owner?
Is this residence owned or rented?
What is the ultimate beneficial owner's marital status?
Please enter information about the beneficial owners of this yacht below.
What is your relationship to the beneficial owner(s)?
Please describe your relationship with them.
Please provide the primary home address for one of the beneficial owners.
Is this residence owned or rented?
Is the yacht titled in the name of a corporation?
What is the name of the corporation?
Was this corporation established for the sole purpose owning this yacht?
Please provide a brief explanation of the other purpose(s) for which this corporation exists.
Driver Information
Who will drive the yacht?
What is your drivers license number?
Which state are you licensed in?
What state/country are you licensed in?
Has you had any accidents or violations within the last four years? (Please check all that apply)
What type of accident was it?
Please provide a brief description of the accident.
What date did this accident occur?
MM slash DD slash YYYY
Is there a second accident for this driver?
What type of accident was it?
Please provide a brief description of the second accident.
What date did the second accident occur?
MM slash DD slash YYYY
What type of violation did this driver have?
Please provide a brief description of the situation that resulted in the violation.
What date did this violation occur?
MM slash DD slash YYYY
Is there a second violation for this driver?
What type of violation was it?
Please provide a brief description of the second violation.
What date did the second violation occur?
MM slash DD slash YYYY
Is there another driver?
Please enter their full name exactly as it appears on their license.
What is this driver's license number?
Which state is this driver licensed in?
What state/country are you licensed in?
What is this driver's date of birth?
MM slash DD slash YYYY
Has this driver had any accidents or violations within the last four years? (Please check all that apply)
What type of accident was it?
Please provide a brief description of the accident.
What date did this accident occur?
MM slash DD slash YYYY
Is there a second accident for this driver?
What type of accident was it?
Please provide a brief description of the second accident.
What date did the second accident occur?
MM slash DD slash YYYY
What type of violation did this driver have?
Please provide a brief description of the situation that resulted in the violation.
What date did this violation occur?
MM slash DD slash YYYY
Is there a second violation for this driver?
What type of violation was it?
Please provide a brief description of the second violation.
What date did the second violation occur?
MM slash DD slash YYYY
Please enter the helmsman's full name.
Please enter the helmsman's drivers license number.
Which state is the helmsman licensed in?
Please enter where the helmsman licensed?
What is the helmsman's date of birth?
MM slash DD slash YYYY
Has this driver had any accidents or violations within the last four years? (Please check all that apply)
What type of accident was it?
Please provide a brief description of the accident.
What date did this accident occur?
MM slash DD slash YYYY
Is there a second accident for this driver?
What type of accident was it?
Please provide a brief description of the second accident.
What date did the second accident occur?
MM slash DD slash YYYY
What type of violation did this driver have?
Please provide a brief description of the situation that resulted in the violation.
What date did this violation occur?
MM slash DD slash YYYY
Is there a second violation for this driver?
What type of violation was it?
Please provide a brief description of the second violation.
What date did the second violation occur?
MM slash DD slash YYYY
Please enter the captain's full name.
Please enter the captain's drivers license number.
Which state is the captain licensed in?
Please enter where the captain licensed?
What is the captain's date of birth?
MM slash DD slash YYYY
Has this driver had any accidents or violations within the last four years? (Please check all that apply)
What type of accident was it?
Please provide a brief description of the accident.
What date did this accident occur?
MM slash DD slash YYYY
Is there a second accident for this driver?
What type of accident was it?
Please provide a brief description of the second accident.
What date did the second accident occur?
MM slash DD slash YYYY
What type of violation did this driver have?
Please provide a brief description of the situation that resulted in the violation.
What date did this violation occur?
MM slash DD slash YYYY
Is there a second violation for this driver?
What type of violation was it?
Please provide a brief description of the second violation.
What date did the second violation occur?
MM slash DD slash YYYY
Boating History & Experience
How many years of boating experience does the owner have?
Please select the applicable option(s) below.
Please provide the following information about previous vessels owned.
Please provide the following information about previous vessels rented/borrowed.
Has the owner(s) taken any boating courses?
Please select the course(s) the owner has taken.
Please enter the other boating course(s) the owner has taken.
Helmsman's Experience
How many years of boating experience does the helmsman have?
Please provide the following information about vessels the helmsman previously piloted.
Please select the course(s) the helmsman has taken.
Please enter the other boating course(s) the helmsman has taken.
Captain's Experience
How many years of boating experience does the captain have?
Please provide the following information about vessels the captain previously operated.
Please select the course(s) the captain has taken.
Please enter the other boating course(s) the captain has taken.
Yacht Information
Is this yacht a new purchase?
What is the purchase price?
What is the purchase date?
MM slash DD slash YYYY
Will this yacht purchase be financed?
Is there an insurance policy currently in place for this yacht?
What is the name of the current insurance company?
What is the current insurance deductible?
What is the current insurance premium?
What is the current value of the yacht?
What date would you like coverage to commence?
MM slash DD slash YYYY
Is there a lien on this yacht?
What is the name of the lending institution/bank providing the financing?
What is the address of the lending institution/bank?
What is the loan number?
What is the yacht's name?
What is the yacht's model year?
Has the yacht been renovated?
What year was the yacht renovated?
Please provide a brief overview of the renovation.
What is the name of the yacht's builder/manufacturer?
What is the yacht's model?
What is the length of the yacht?
What is the gross tonnage of the yacht?
What is the yacht's superstructure material?
What material was used for the construction of the yacht's superstructure?
What is the yacht's hull material?
What material was used for the construction of the yacht's hull?
What is the hull ID number/serial number (HIN)?
Is there a recent condition and valuation survey available?
Please upload a copy of the condition and valuation survey, if available.
What type of hull does this yacht have?
Please enter the hull type of this yacht?
How many engines does this yacht have?
What type of fuel does this yacht run on?
Please enter the type of fuel this yacht runs on?
What type of engine(s) does this yacht have?
Please enter the type of engine that powers this yacht.
What is the engine year?
What is the name of the engine manufacturer?
Please enter the engine serial number(s).
What is the total horsepower?
What is this yacht's top speed?
Pleas select the additional equipment onboard this yacht.
Please enter any other additional equipment onboard this yacht.
Was this yacht purchased as salvage or have any existing or prior damage?
Have there been any previous yacht/boat insurance claims?
Please enter information about any yacht/boat insurance claims below.
Navigation, Usage & Mooring
Please select the yacht's navigation area.
Please describe the desired navigation area.
Is a secondary navigation area required?
Please provide a description of the secondary navigation area.
How will the yacht be used?
Please describe how this yacht will be used.
How many passenger charters will this yacht do annually?
Please select the type(s) of charter(s) this yacht will do.
Please provide a brief description of the type of charter this yacht will do.
Please describe the commercial use.
Will this yacht be used for racing?
Will anyone be living onboard this yacht?
What is the name of the marina/facility where the yacht is moored in the summer?
What type of location is the summer marina/facility?
How will the yacht be moored at this marina/facility in the summer?
Please enter the address where the yacht is kept in the summer.
Is the winter mooring location different than the summer location?
What is the name of the marina/facility where the yacht is moored in the winter?
What is the address where the yacht is moored in the winter?
What type of location is the winter marina/facility?
How will the yacht be moored at this marina/facility in the winter?
Does this yacht lay-up out of commission?
When does the lay-up period start?
MM slash DD slash YYYY
When does the lay-up period end?
MM slash DD slash YYYY
How is the yacht stored during the lay-up period?
Please select the conditions that apply to this yacht while it is laid-up.
Is the yacht currently held for sale?
Crew
Is there a paid crew?
How many full-time crew members are there?
How many part-time crew members are there?
Please list the nationalities of the crew members.
What is the combined monthly payroll for all crew members?
What is the captain's annual salary?
Have there been any previous claims for the crew?
Please provide details on the claims for the crew member(s).
Tenders, Toys and Fine Art Onboard
Is there a tender onboard this yacht?
Please provide the requested details about the tender.
What is the value of the tender, including the engine?
Please describe how the tender is being transported.
Is there a trailer?
Please provide details on the trailer and its value.
Will there be any toys kept onboard this yacht? (Ex. Jet skis)
Please select the toys that will be kept onboard this yacht.
What are the other types of toys that will be kept on this yacht?
What is the total value of all the toys kept on this yacht?
Is there fine art onboard this yacht?
What is the value of the fine art onboard this yacht?
Documents and Comments
Please use this field to upload any relevant insurance documents. (I.e. Current policy declarations pages, etc...)
Please enter any additional remarks in the space below.
How did you hear about us?
Please share who referred you to us.
Please share what you typed into Google.
Please share how you heard about us.
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.
