Vessel Owner:
Policy is to be issued in the name of:
Name
Address
City
State
Country
Zip
Name and address of beneficial owner (if different than above):
Name
Address
City
State
Country
Zip
Loss Payee:
Name
Address
City
State
Country
Zip
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:
Age:
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
c No
Reason:
Current Carrier:
Expiration Date:
Premium: $
Loss Experience – Owner & Vessel:
Owner/Beneficial Owner insurance losses? Please give company name(s), date(s) of loss(es), nature of loss(es) and
amount(s) paid.
Company:
D/O/L:
Amount: $
Cause:
Has this vessel ever sustained any losses? If so, please detail date, cause, type and repair cost.
D/O/L:
Amount: $
Cause:
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:
c Captain
c Owner
c Other:
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Elite Yacht Program®
Mega-Yacht Application
MA18369 (1/2008)
ace recreational
marine insurance
Crew:
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 References
c Dates of employment
c Safety courses taken, i.e., CPR and First Aid
c Reason for leaving
c La