Policy is to be issued in the name of:
Name and address of beneficial owner (if different than above):
Are there any other individuals or entities with a financial interest in this vessel that request being named on this policy?
If yes, please identify and explain their interest:
Owner/Beneficial Owner’s Experience:
Years as owner (All boats):
Size and types of vessel(s) owned:
Describe owner’s occupation/source of income with name & address for business:
Who is authorized to place insurance for the vessel?
What is their relationship to the Owner/Beneficial Owner?
Has insurance ever been declined or cancelled? c Yes
Loss Experience – Owner & Vessel:
Owner/Beneficial Owner insurance losses? Please give company name(s), date(s) of loss(es), nature of loss(es) and
Has this vessel ever sustained any losses? If so, please detail date, cause, type and repair cost.
In the event of a threat to the safety of the vessel or crew, who would have the ultimate responsibility to make decisions
concerning the action(s) to be taken to protect the vessel and/or crew?
Make ONE selection only:
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Elite Yacht Program®
Please provide a copy of current licenses and detailed resumes for each crew member. The resume should include the
following minimum information for the past five years:
c Previous vessels on which employed
c Loss history
c Rank or position on each vessel
c Dates of employment
c Safety courses taken, i.e., CPR and First Aid
c Reason for leaving