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6 Pack and Passenger Vessels
Yachts & Pleasure Crafts
Type of Coverage
Type of Coverage *
Date of request *
Saw ad in:
Contact Name *
Registered Owner of Vessel
Name of Vessel
Home Port/ State:
Type of Fishing
Maximum miles offshore:
In Board Engine?
Make/Model of Engine:
Year Vessel Built:
Built at what yard?:
Please select hull material
Glass over Wood
Current Insurance Company
Present Insurance agent
Date Insurance Expired/Needed:
Has insurance ever been canceled or declined?:
If yes, why:
Claims for owner for any vessels owned or operated wthin last 5 years
Please describe any claims in the last 5 years
Have you and/or affiliated companies been involved in bankruptcy proceedings?
Has insurance been denied cancelled or non-renewed on Applicant and/or affiliated companies in the last 5 years?
Years in current operation?
Please advise and explain prior experience in trade/operation.
Is any non-marine work performed?
Is any work performed on commercial vessels?
Do you engage in any diving operations with regard to work performed?
If yes please explain
Besides the owner/operator, how many are employed by this business?
Does Applicant own any watercraft used in the course of business.
If yes please explain use of watercraft.
Does Applicant own any heavy equipment, or any individual tools, or any one piece of equipment in excess of $2,500 for use in the business?
If yes please list
Transport by Vehicle individual vessels worth not more than
Maximum values of marine equipment and vessel(s) at applicant's premises in their care, custody, and control any one time does not exceed
What is the value of the most expensive vessel the Applicant will perform work on?
Other than cabinetry (and other items made by a carpenter), does the Applicant manufacture any products?
If yes. Please list products.
What are the total number of paid and outstanding insurance losses for the last three years?
What is the total value of claims in 16?
What are the anticipated annual gross receipts for upcoming year?
Enter Last Survey Date
All recommendations been complied with:
Vessel Mortgage Balance:
* = Required Field
Warwick | fairhaven | point judith
33 College Hill Rd. Bldg 10
Warwick, RI. 02886
7 Water St.
Fairhaven, MA. 02719
Point Judith Office:
270 Great Island Rd.
Narragansett, RI. 02882
Call (800) 767-6687
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