CM 6056-0605
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COMMERCIAL WATERCRAFT RENTAL
INSURANCE APPLICATION
Requested Effective Date
General Agent Code: _______ Producer Code: ______________
Applicant Name
Producer Name & Address
Mailing Address
City / St. / Zip Code
Principal Contact; Title
Producer Phone Number: ______ _____ ____________
Fax Number: ______ _____ ____________
Physical Address Of Operation; List All Locations
ADDITIONAL INTEREST(S)
Mooring County
Phone Number
Relationship To Applicant:
LIENHOLDER
PREMIUM FINANCE COMPANY
Name And Address
Name And Address
How Are Watercraft Used By This Operation?
What Is The Experience Of The Principals With This Type Of Operation?
ORGANIZATION
OPERATING PERIOD
OPERATING FROM
How Many Years Has Applicant Owned/Operated This Business? ___
Individual
Year Round
Marina
Partnership
Seasonally
Beach Front
How Many Years Has Applicant Operated From This Location? _____
Corporation
Public Ramp
Joint Venture
From: ____________
Other: _________
Gross Receipts For This Operation Last Year $________________
Other:
________________
To: ____________
Projected Gross Receipts For This Year $________________
List And Describe All Other Commercial Activities Conducted On The Premise, Whether Owned Or Non-Owned:
If Owned, Is There Other Insurance In Force?
No
Yes, Explain:
Previous Insurance Carrier: ___________________________
Expiration Date: ___________
Has Any Company Ever Canceled Or Non-Renewed Insurance For This
Applicant? (Missouri residents Need Not Answer)
No
Yes, Explain:
NAVIGATION LIMITS DESIRED & RANGE OF NAVIGATION
US INLAND RIVERS/WATERWAYS ONLY
COASTAL Up To 25 Miles Offshore
ATLANTIC
PACIFIC
GULF
BAHAMAS
GREAT LAKES & TRIBUTARIES
LAKE MEAD, POWELL