Application form

Name of Insured

Date of birth

Nationality

Address

Email address

Phone number

Sailing experience &/or qualifications

Claims history

NO

YES

(have you had any claims with this or any other vessel in the past 5 years)

Have you ever been refused Insurance?

NO

YES

(have you had any claims with this or any other vessel in the past 5 years)

Have you ever been charged with any offence relating to dishonesty, theft, fraud, arson, robbery and any criminal record?

NO

YES

(have you had any claims with this or any other vessel in the past 5 years)

Vessel name

Make/Model

Length – feet/meters

Year Built

Flag

Port of Registry

Hull material

Hull type

(Mono, Catamaran, Trimaran)

Purchase Price

(If the insured value is greater than the purchase price justification for the increase will be required)

Purchase date

Type of Drive Unit

Make/Model

Year Built

Number of engines & Total Horsepower

Fuel type

Tender - Make/Model

Length – feet/meters

Year Built

Outboard Motor - Make/Model

Horsepower

Year Built

Currency

USD

EUR

Vessel

Tender/Outboard motor

Personal Effects

(limit any one item USD/EUR 1,000 unless specifically declared*)

Jet Ski/Jet Boat

Trailer/Cradle

Liferaft

Additional Items (*)

*Details and values to be advised by separate schedule

TOTAL SUM TO BE INSURED:

Private Pleasure

YES

NO

Skipper Charter

YES

NO

Bareboat Charter

YES

NO

Cruising area

Homeport/Marina

Is the vessel used for racing?

YES

NO

Attachment date insurance

Any other information

IMPORTANT NOTICE

Please read the following carefully before you sign and date the Declaration below.

The questions on this proposal form and any other details we specifically request relate to facts which we
consider material to underwriting this insurance. However, because no list of questions can be exhaustive please
consider whether there is any other material information which is known to you which could influence our
assessment and acceptance of the risk. FAILURE TO DISCLOSE ALL MATERIAL FACTS WHETHER OR NOT THE SUBJECT OF A
SPECIFIC QUESTION MAY INVALIDATE YOUR INSURANCE.
We recommend that you should keep a record, including copies of letters and this Proposal Form, of all
information supplied to us for the purpose of entering into this insurance.
All personal information supplied by you will be treated in confidence and will not be disclosed to any third
parties except where your consent has been received or where permitted by law. In order to provide you with
products and services this information will be held in our data systems.
Underwriters may pass your personal data to other companies for processing on its behalf. Some of
these companies may be based outside Europe in countries which may not have laws to protect your
personal data, but in all cases they will ensure that it is kept securely and only used for the
purposes for which you provided it. Details of the companies and countries involved can be provided to
you on request.

DECLARATION

Before signing the Declaration please check your answers carefully particularly if this Proposal Form is not
completed in your own hand.

I/We declare that to the best of my/our knowledge and belief the answers given are true and complete.
I/We agree that if any answers have been completed by any other person, such person shall for that purposes be
regarded as my/our agent and acting on my/our behalf, and not the agent of Underwriters.
I/We declare that this Proposal Form is for insurance in the normal terms and conditions of the Insurer’s
policy.
I/We agree that the information provided on this Proposal Form and any information supplied by me/us shall be
incorporated in and form part of the insurance contract.

I agree with the above terms

Aanvraagformulier pleziervaartuigen

TOTAL SUM TO BE INSURED: