Insurance Agents Inquiry - Seawave Yacht and Boat Insurance underwritten by Lloyd's of London

Contact: Laura Sherrod
Toll Free: 800.330.3370
Fx: 954.525.1183
1300 S.E. 17th St. Suite 220
Fort Lauderdale, Florida 33316
lsherrod@atlassinsurance.com
Seawave Yacht Insurance is a division of Atlass Insurance

Welcome, Insurance Agents.

Please fill out the form below to complete your yacht insurance inquiry.

Applicant's Information

Name of Owner :

Email Address:

Date of Birth: (mm/dd/yyyy)

Street Address:	Telephone Number Home: Work:
City, State, Zip

Country:

Occupation:

Yacht Description

Manufacturer/ Builder:

Model:

Registration / Documentation Number:

Year Built:

Horsepower:

Each:

Max Speed:

Length:

Yacht Type:

Power
Sail

Multi -hull
Houseboat

Construction:

Fiberglass
Aluminum
Wood

Steel
Kevlar/Carbon Fiber
Other

Yacht Use:

Private Pleasure
Bare Boat Charter

Captain Charter
Racing

Name of Yacht:		Hull Identification Number:
Date Purchased:		Purchase Price: $
Engine Manufacturer/Model:	Year Built:	Serial Number(s):

Fuel Type:

Diesel
Gas

Power Type:

Inboard
Outboard
Inboard/Outboard

Engine(s):

Twin
Single
Other

Fuel Tanks:

Metal
Fiberglass

Auxiliary Generator
Manufacturer:

Auxiliary
Generator:

Diesel
Gas

Yacht Survey

Current Survey:
Yes No

Date of Survey:

Afloat Drydock

Name of Surveyor:

Market Value:

Replacement Cost:

Navigation/Safety Equipment

VHF Radio
Engine Alarm
Auto Fire Ext.

Radar
Sat Nav
Anti Theft Devices

RDF
GPS
Fume Detector

Auto Pilot
Compass
Depth Finder

Other

# of hand held fire extinguishers

Training/Experience

Years boating Experience:

Owned Boats Since:

Driver's License Number:

Boating Courses:
None
U.S. Power Squadron
U.S. Coast Guard Auxiliary

Other experience or training:

Boats Previously Owned (Dates owned, Manufacturer, Type, Size, Waters Navigated)

Loss History (Dates, Cause, Amounts)

Other Operators: (List) Age, Experience, Driver´s License Number:

Yacht Tender

(may be insured separately for an additional premium)

Year:

Length:

Manufacturer:

Model:

Hull ID Number:

Engine Year:

Engine Manufacturer:

Engine H.P.:

Engine Serial Number:

Yacht Trailer

(may be insured separately for an additional premium)

Year:

Manufacturer & Model:

Serial Number:

Number of Axles:

Capacity:

Stored on Trailer:
Yes No

Insurance Coverages Requested

Coverage	Amount of Insurance	Deductible
Yacht Hull and Machinery	$	$
Named Windstorm Deductible		$
Dinghy/Tender/Outboard	$	$
Trailer	$	$
Liability (P&I)	$	$
Medical Payments	$	$
Personal Effects	$	$
Uninsured Boaters	$	$
Crew Liability	$	$

Navigation Area:

East Coast U.S. Florida Bahamas Gulf Caribbean Other

Lay Up:

From To

Ashore Afloat

Home Port:

Exact Hurricane Season Mooring Location: (Marina/Address,City, State, Zip)

Lienholder Information

Mortgagee Name and Adress:	Loan Number:
	Loan Balance:

Other Information

Explain all "Yes" Responses In Remarks:	Yes	No	Remarks
Is yacht ever chartered to others with captain?
If yes, is yacht owner operated?
Is yacht ever chartered to others without captain?
Is yacht used commercially or for business purposes?
Do you employ a paid captain or crew? If so how many?
Is yacht used for water skiing or recreational diving?
Was any operator involved in a marine loss in the last 10 years (Insured or not?)
Has any carrier cancelled, non-renewed or declined coverage?
Is the yacht used for racing?

For fare paying passenger vessels, advise the maximum/average # of passengers per trip
/ # trips annually

ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER, FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION IS GUILTY OF A FELONY OF THE THIRD DEGREE

The completion and signing of this application does not bind the APPLICANT or this COMPANY to effect insurance on this risk; it is submitted for purposes of rating and quotation only. If accepted by this COMPANY it is agreed the information furnished herein shall be the basis of the contract should a policy be issued.

Applicant Signature:	Date:	Producer Remarks
Producer Signature:	Date:
Current Insurer:
Policy Effective Date:	Annual Premium: $

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