UNITED
YACHT INSURANCE
                   

United Yacht Insurance

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PLEASE CALL US AT 800-990-9283 AND WE CAN DISCUSS YOUR PARTICULAR INSURANCE NEEDS, OR FILL IN THE FORM BELOW AND WE WILL RESPOND TO YOU SHORTLY.

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APPLICANT'S PERSONAL INFORMATION
Full Name:
Address:
City:
State/Province:
Zip code/Postal zone:
Country:
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:
If your builder is not listed above please add your builder here:
MODEL:
TYPE OF VESSEL:
LENGTH:
PURCHASE PRICE OF VESSEL:
DATE OF PURCHASE:
FLAG: US Foreign
MAXIMUM SPEED:
HULL TYPE:
HULL MATERIAL:
ENGINES: NUMBER: FUEL TYPE:
HORSEPOWER EACH.........
MANUFACTURER..............
DRIVE TYPE........................
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? to
If laid up, is vessel stored:
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:
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: Survey Date
Survey conducted:
LIABILITY COVERAGE  (Protection and indemnity)
Paid Crew Number of Paid Crew:
Comments
 
UNITED YACHT INSURANCE
 
 
by W.R. Hodgens Marine Insurance, Inc.
2015 SW 20th St., Suite 100   Fort Lauderdale, FL 33315
Ph: 954-523-6867 Fax: 954-523-6488
Toll Free USA:  800-990-WAVE (9283)
 
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