Get Chubb Ma-28741 2010

Marine Insurance Application Requested Policy Type Yachtsman Policy Agreed Value for vessels 27 and greater Boatsman Policy Agreed Value for vessels less than 27 Departure Yacht Policy ACV for vessels 27 and greater High Performance ProgramSM ACV Charter Policy Agreed Value Departure CharterSM Policy ACV Contract ID INSURED INFORMATION POLICY TO BE ISSUED IN THE NAME OF NAME OF BENEFICIAL OWNER IF DIFFERENT / ADDITIONAL OWNER RESIDENCE ADDRESS STATE CITY ZIP MAILING ADDRESS IF DIFFERENT OWNER / OPERATOR INFORMATION PRIMARY OWNER S SSN Own PRIMARY OWNER / BENEFICIAL OWNER S OCCUPATION DOES PRIMARY OPERATOR HOLD A U.S.C. G* LICENSE Yes IS THERE A PAID CAPTAIN No IF YES ATTACH COPY CAPTAIN HOLD A U*S*C. G* LICENSE D/O/B BOATING COURSES DRIVER LICENSE / STATE Other TOTAL OF PAID CREW IF YES ATTACH RESUME REGULAR OPERATOR NAME S Rent YRS BOATS OWNED INCL* CAPTAIN PREVIOUSLY OWNED VESSELS LENGTH / MAKE / MODEL LOSS INSURANCE HISTORY PREVIOUS / CURRENT INSURANCE COMPANY NAME AND PREMIUM HAS OWNER EVER HAD INSURANCE CANCELLED NON-RENEWED OR DECLINED IF YES GIVE COMPANY NAME S DATE S AND REASON S HAS ANY OWNER OR OPERATOR SUSTAINED ANY MARINE CLAIMS OR LOSSES IF YES PROVIDE COMPANY NAMES DATE S OF LOSS/CLAIM CAUSE AND AMOUNT PAID DOES VESSEL HAVE UNREPAIRED DAMAGE OR WAS IT PURCHASED AS SALVAGE IF YES PROVIDE DETAILS VESSEL EQUIPMENT INFORMATION YEAR BUILT LENGTH FEET BUILDER/MANUFACTURER PURCHASE PRICE PURCHASE DATE MODEL NAME HULL ID / DOCUMENTATION VESSEL TYPE POWER/SAIL SINGLE/MULTI-HULL VESSEL S NAME MAXIMUM SPEED MPH LAST MARINE SURVEY DATE MAST MATERIAL IF SAILBOAT HULL MATERIAL Fiberglass Wood Steel Aluminum OF ENGINES TOTAL H. P. ENGINE/PROPULSION DRIVE SYSTEM Outboard Inboard Inboard/Jet Inboard/Surface Piercing ENGINE MANUFACTURER MA-28741a 07/11 I/O FUEL TYPE Inboard/POD Gas w/ No Fume Detector Diesel None Hybrid/Electric H. P. EACH ENGINE SERIAL NUMBERS OUTBOARD ONLY Page 1 of 3 continued Named Insured EQUIPMENT check all that apply Built-in Auto Fire Extinguishing System Fume Detector Carbon Monoxide Detector Alarm/Monitoring System MANUFACTURER/MODEL/TYPE TRAILER MANUFACTURER YEAR BUILT PURCHASE DATE TRAILER VALUE TRAILER SERIAL NUMBER TENDER/DINGHY COVERAGE OPTIONS Actual Cash Value and Vessel Hull Deductible Amount applies Tender/Dinghy Not Scheduled No Charge However if policy type is Yachtsman or Boatsman then tenders 17 ft or less in length with motor 40 hp or less are subject to 250 deductible Deductible Option Loss Settlement Option Agreed Value Tender Value Included in vessel hull limit Not Included in vessel hull limit Manufacturer Tender Year Model ft Purchase Date Length Motor Year Motor Mfg. Motor HP Motor Value Serial outboards only Motor Type Inboard/Outdrive OPERATION OF VESSEL WATERS TO BE NAVIGATED LAY UP PERIOD NOT APPLICABLE IF REQUESTED POLICY TYPE IS BOATSMAN From MM/DD To IF LAID UP VESSEL IS DECOMISSIONED Ashore BERTH/MOORING LOCATION OF VESSEL JUNE - NOVEMBER Afloat Afloat w/ Bubbler Marina Name Afloat Dock/Slip Afloat Mooring Mooring Address On Hydraulic Lift On Trailer Rack Storage Inside Rack Storage Outside On Jack Stands or Stilts Mooring State Mooring City Mooring Zip Code Country VESSEL IS check all that apply Lived aboard on a permanent / semi-permanent basis Raced in other than club races days/year Bareboat Chartered Chartered w/ Captain/Crew INSURANCE COVERAGE REQUESTED EFFECTIVE DATE OF COVERAGE Limit Property Damage Liability Coverage incl* Pollution1 Medical Payments per person Uninsured Boater L HCA passengers max.