Please complete the following in as much detail as possible to assure we can provide you with the most competitive rate, or phone us at 1-800-990-WAVE for immediate quote on our yacht policy or other forms of marine coverage. APPLICANT'S PERSONAL INFORMATION Full Name: Address: City: State/Province: Zip code/Postal zone: Country: Drivers License State and Number:     --- Select --- AL AK AP AR AZ CA CO CT DC DE FL GU GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VI VT WA WI WV WY Telephone: Fax: E-mail: Occupation: Date Of Birth: Years of boating experience: Size and builder of previous boats owned: Are course/member certificates available? Power Squadron USCG Auxillary USCG Captain License Other License Motor vehicle driving record past 5 years: Are there other operators of this vessel? Yes No VESSEL INFORMATION NAME OF VESSEL: YEAR: MANUFACTURER/BUILDER: MODEL: TYPE OF VESSEL: --- Select --- Sail Yacht Motor Yacht Other LENGTH: PURCHASE PRICE OF VESSEL: DATE OF PURCHASE: FLAG: US Foreign MAXIMUM SPEED: HULL TYPE: --- Select --- Catamaran Other HULL MATERIAL: --- Select --- Fiberglass Aluminum Steel Wood Other ENGINES: NUMBER: --- Select --- 1 2 3 FUEL TYPE: --- Select --- Gas Diesel HORSEPOWER EACH......... MANUFACTURER.............. --- Select --- Caterpillar Crusader Cummins Detroit Evinrude GM Honda John Deere Lehman Mercruiser MTU Perkins Volvo Yamaha Yanmar Other DRIVE TYPE........................ --- Select --- Inboard Outboard In/outboard Other EQUIPMENT: AUTO FIRE EXTINGUISHERS VESSEL USAGE AND LOCATION PRIVATE PLEASURE PART TIME CHARTER FULL TIME CHARTER IF CHARTER- MAX. NUMBER PAYING PASSENGERS/GUESTS: WHERE IS THE VESSEL MOORED? NAVIGATION LIMITS Waters navigated next twelve months: Is vessel ever laid-up? Yes No What months is she out of commission? --- Select --- Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec to --- Select --- Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec If laid up, is vessel stored: --- Select --- Ashore In Water Will anyone be living aboard the vessel during the policy period? Yes No PRESENT AND PAST INSURANCE INFORMATION PRESENT INSURANCE CO.: EXPIRATION DATE OF POLICY: CURRENT PREMIUM: OWNED BOATS SINCE: Have you had any yacht insurance claims in the past 10 years? Yes No Please enter the year, amount, and a brief outline of the loss/claim. COVERAGES REQUESTED Hull and equipment value:$ Tender/Dinghy $ Year Trailer............ $ Year Survey Available: --- Select --- No Yes Survey Date Survey conducted: --- Select --- Afloat Ashore LIABILITY COVERAGE  (Protection and indemnity) --- Select --- $100,000 $300,000 $500,000 $1,000,000 Other Paid Crew --- Select --- Yes No Number of Paid Crew: Comments

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