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Yacht Insurance Proposal Form
Details of Proposer
Insured’s full namefull name
Addressfull name
Work Phonefull name
Home Phonefull name
Faxfull name
Mobile Phonefull name
Name of Employerfull name
Position heldfull name
Insurance is to be for 12 months fromfull name
Finance/mortgage companyfull name
Owner's Nationalityfull name
Details of Vessel
Name of vesselfull name
Type – Motor/Sailfull name
Port of Registryfull name
Buildersfull name
Year Builtfull name
Licence Nofull name
Material of hull (if wood state method of construction)full name
Material of Mast, Rigging and Sailsfull name
Lengthfull name
Beamfull name
Draftfull name
Tonnagefull name
Make of engine(s)full name
Horsepower of eachfull name
Engine number(s)full name
Maximum Design Speedfull name
Fuel usedfull name
Type of engineto order
Surface Driveto order
Insured Values
Hull and equipment including inboard engine (if any)
Purchase Datemake a booking
Purchase Pricefull name
Insured Valuefull name
Outboard motor(s) to parent vessel
Purchase Datemake a booking
Purchase Pricefull name
Insured Valuefull name
Dinghy/tender to parent vessel N.B. (Must be permanently marked with name of parent vessel)
Purchase Datemake a booking
Purchase Pricefull name
Insured Valuefull name
Outboard Motor(s) to dinghy/tender
Purchase Datemake a booking
Purchase Pricefull name
Insured Valuefull name
Personal effects
Purchase Datemake a booking
Not Applicable
Not Applicable
Special equipment – Please attach list with values
Purchase Datemake a booking
Purchase Pricefull name
Insured Valuefull name
Total Sum to be insured
Not Applicable
Not Applicable
Total Sum to be insuredfull name
Type of insurance cover required?full name
Do you wish in addition to cover:
Masts, spars and sails against racing risksto order
If “Yes”, state total replacement value of these itemsfull name
Waterskiing, aquaplaning or any similar sport?to order
If “Yes”, please advise type of activity (e.g. Wake boarding, doughnuts, banana boats, waterskiing etc.) and limit of liabilityfull name
Outboard motors against dropping or falling overboard?to order
Limit of Third Party Liability required?full name
How many years experience have you had in handling craft? State if permanent, professional, or other crew will be employedfull name
What accidents/incidents/losses or insurance claims have happened during the past five years in connection with any vessel you have sailed or owned?full name
Have you had an insurance for any vessel? If so, for what reason.
(a) Declined?full name
(b) Cancelled?full name
Is the vessel used for private pleasure purposes only?to order
Is the vessel used for corporate entertainment?to order
Is the vessel used for paid charter?to order
Is the vessel used as a houseboat?to order
What cruising range is to be covered?full name
Will any major alterations or major repairs take place within the next 12 monthsfull name
Please give details of moored security and precautions taken against the vessel being stolen.full name
Have you or any other person you have allowed or may allow to use your craft, ever been charged with or convicted of any offence involving dishonesty of any kind, e.g. arson, robbery, smuggling, theft or handling stolen goods?something more
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Details of fire extinguisher system:
• Please advise if vessel is fitted with a fixed fire fighting system in the engine room and where the manual operating controls are situated:full name
• If vessel has a galley, please advise what fire fighting systems are installed in this areafull name
• Please advise the number of hand held fire extinguishers on board and their locationsfull name
Please note that insurance company requirements for fire fighting or preventative systems vary. You must check that your system complies with Underwriters requirements and ensure that it is fully serviced and operational at all time
Has the vessel been surveyed by a qualified surveyor? If so, please provide a copy.to order

Declaration

All material facts must be disclosed to Underwriters whether or not the subject of a specific question above. A material fact is one which a prudent Underwriter would regard as likely to influence the acceptance or assessment of the proposal. Non-disclosure or misrepresentation of a material fact may result in the insurance being void. If you are in any doubt whether facts would be considered material, you should disclose them. Should something become known or a matter arise during the currency of your insurance which could be considered to be a material fact this should also be advised to Underwriters immediately. I declare that the particulars and answers are correct and complete in every respect to my knowledge and belief. I agree that this proposal and declaration shall form the basis of the contract of insurance between me and the Underwriters if a policy is issued. I further declare and agree that if the statement and particulars above have been completed in the handwriting of any other person other than the undersigned, such person is deemed to be the agent of the proposer for the completion purposes.

Datemake a booking
Full Namefull name
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