Before completing this proposal, please note specially that failure to disclose all material information. i.e. information which is likely to influence the acceptance of the risk and the terms applied, could invalidate the insurance. If you are in any doubt as to whether any information is material, it should be disclosed.

1. Person applying for Insurance THE PROPOSER
A) Name in full
B) Date of Birth
C) Occupation
D) Address
E) E-Mail Address
F) Name and Address of Mortgagee or other insured as applicable
G) Have you or any member of your family normally residing with you, or directors where the Proposer is a limited company, ever been convicted of any offense other than driving offenses?	No Yes
H) Have you or any person in (G) above suffered from diabetes, epilepsy, heart condition or any other physical or mental disability, infirmity or disease, or  any condition controlled by drugs? If "Yes" to either question give details	No Yes
2. BOAT HANDLING EXPERIENCE AND INSURANCE RECORD
A) What are your special qualifications for Boat Handling? E.g. Yacht Master Certificate
B) Number of years as owner of this type of craft
C) What accidents, loss or insurance claims have happened during the past 5 years in connection with any vessel you have sailed or owned?
D) Have you previously insured any vessel?	Yes No
if "Yes", state which insurer
E) Have you ever had an insurance on your boat
i)  ever been cancelled?	No Yes
ii) refused at renewal?	No Yes
iii) renewed only at increased terms?	No Yes
If so state circumstances
3. PERIOD OF INSURANCE
12 months from
4. BERTH
Vessel will be based
Ashore when not in use	No Yes
Afloat on moorings	No Yes
at:- (If marina, state name. If not a marina give details of type of mooring and precise location)
5. DO YOU REQUIRE THE VESSEL TO BE INSURED DURING ANY INLAND TRANSITS?	Yes No
If Yes, give details
6. HOW AND WHERE WILL THE VESSEL BE PROTECTED IN CASE OF HURRICANE WARNING?
7. LAID UP OUT OF COMMISSION
Will the vessel be laid up ashore and out of commission for a part of the year?	No Yes
Please show dates:
Give details of location, where the vessel will be stored whilst laid up and caretaking arrangements
8. NAVIGATING LIMITS
State Cruising Range Required
9. USE OF VESSEL:
A) Private Pleasure Only?	Yes No
If No, state intended use
B) Do you have a full time professional Master?	Yes No
If "Yes" please give details of his sailings experience with this type of boat and this particular boat
C) Will any other person be allowed to be in charge?	Yes No
If "Yes" give details
D) Will the vessel be sailed single-handed?	Yes No
E) Will the vessel be used for waterskiing, aquaplaning or any similar sport?	No Yes
If "Yes" give details
F) Will the vessel be involved in racing?	No Yes
If "Yes" give details
10. HULL DETAILS
Name of Vessel
Type/Class
Manufacturer
Serial |Number or Reg. No.
Year Built
Length Overall
Beam
Material of Hull
Max. designed speed with present engine/s
MAIN ENGINE DETAILS
Type
Inboard	No Yes
Outboard	No Yes
Single	No Yes
Twin	No Yes
Make/Model
Engine Serial Number(s)
Horsepower of each
Fuel Used
Year of Make
If inboard engine(s), are they the original engines installed by the builder of the Hull?	Yes No
If No, please give details
Has the vessel proposed for insurance been subject to:
a) conversion?	No Yes
b) modification?	No Yes
c) amateur construction?	No Yes
If "Yes" give full details
What system is used for
Lighting
Cooking
Heating
Details of Fire Extinguisher System
Has the vessel been surveyed by a qualified surveyor?	No Yes
If "Yes" please provide copy of report
11. DETAILS OF DINGHY/TENDER TO PARENT VESSEL
Manufacturer
Year Built
Length
Identification/Serial No.
Manufacturers Identification/Serial Number
12. DETAILS OF ANY AUXILIARY OUTBOARD MOTORS  - NOT ALREADY SHOWN ABOVE
13. DETAILS OF TRAILER
Manufacturer
Year Built
Identification/Serial No.
14. SCHEDULE OF INSURANCE REQUIRED
Hull & Equipment including Inboard Engine (if any)
Value to be insured
Date Purchased
Purchase Price
Outboard Motor(s) to Parent Vessel
Value to be insured
Date Purchased
Purchase Price
Special Equipment - attach valued list
Value to be insured
Date Purchased
Purchase Price
Dinghy/Tender to Parent Vessel N.B. Must be permanently marked with name of Parent Vessel
Value to be insured
Date Purchased
Purchase Price
Outboard Motor(s) to Dinghy/Tender
Value to be insured
Date Purchased
Purchase Price
Trailer
Value to be insured
Date Purchased
Purchase Price
Personal Effects (Max $500 insured unless higher figure requested)
Total to be Insured
15. LIABILITY TO THIRD PARTIES
Please state limit of Indemnity required
Do you require cover in respect of liability to and of water sports or persons engaged on similar water sports from your boat? (Restricted limit may apply)	No Yes
16. MEDICAL PAYMENTS LIMIT
Please state higher limit if required ($2,000 applies unless otherwise agreed)
17. RACING RISK EXTENSION (If required for sailing vessels)
Place state total new replacement value of sails, masts, spars, standing and running rigging.
18. Do you wish to bear a voluntary deductible in addition to an compulsory deductible required by the Company? If so, please indicate the additional amount required
19. Any other information which is likely to influence the Company in regard to this proposal.
Declaration I hereby declare that, to the best of my knowledge and belief, the particulars and answers are true and correct and that I have not withheld any information which is likely to influence the decision of the Company with regard to this proposal. Sending this form does not bind the proposer to complete the insurance but it is agreed that this form shall be the basis of the contract should a policy be issued. No liability attaches to the Company until this proposal has been accepted.