Proposal Application Form

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Marine Insurance Application Form

First name
Surname
Address
Zip/Postcode
Email Address
Tel
Tel (Mobile)
Date of birth
Occupation:(Director is not sufficient)
Boating Experience (years)
In which craft?
Relevant Qualifications
Particulars of Vessel
Name
Type or class
Hull Serial Number (see Note 1.)
Builder's name
Country of Registration / Flag:
Year Built
Is vessel a conversion?	No Yes
If Yes was it converted by professional or amateur? Give full details of conversion and by whom, with date:-
Length
Beam
Draft
Sail Area
Hull Material
Date boat purchased
Price paid (include currency)
Date of last survey
Surveyor's Name
Particulars of Engine(s) * Theft cover for outboards will not apply without a serial number.
Engine 1 Make /type
Engine 1 Year
Engine 1 HP /CC
Engine 1 Fuel type
Engine 1 Value
Engine 1 Serial Number *

Engine 2 Make /Type
Engine 2 Year
Engine 2 HP /CC
Engine 2 Fuel type
Engine 2 Value
Engine 2 Serial Number *
Engine 3 Make /Year
Engine 3 Year
Engine 3 HP / CC
Engine 3 Fuel Type
Engine 3 Value
Engine 3 Serial Number *
* Theft cover for outboards will not apply without a serial number.
Are outboards permanently locked to transom or stored in locked premises when not in use?	No Yes
Maximum designed speed of vessel - specify calibration.(If over 17 knots, please note the contents of the Speed Boat Clauses )
Are the following areas fitted with an automatic or remote fire extinguishing system?
Engine room(s)	No Yes
Tank Spaces	No Yes
Galley	No Yes
State the number of fire extinguishers carried
Hand
Remote
Automatic
Gas System
If liquefied petroleum gas (LPG) is used, is the:-
Cylinder kept in self draining cockpit locker	No Yes
Delivery tubing copper or European standard armored type	No Yes
Cruising Range
Do you intend to sail single handed?	No Yes
Please give full details of the cruising range required *
Do you require cover for: (please state Yes or No for each)
Private and pleasure only	No Yes
Charter	No Yes
House Boat	No Yes
Netting/Potting	No Yes
Hire	No Yes
Demonstration	No Yes
Racing	No Yes
Water Sking	No Yes
Night Navigation	No Yes
Salvage and Wreck Removal	No Yes
Details of Moorings
Moored at
Type of Mooring
Period vessel in commission: From
Period vessel in commission: To
Period vessel laid up: From
Period vessel laid up: To
Laid up at
	Afloat Ashore
Sums to be Insured Enter numbers only!
Hull/Machinery/Gear/Equipment only (See Note 4) *
Navigation Equipment (Maximum £75 any item unless specified)
Trailer
Trailer Serial No
Tender/Dinghy/Liferaft
Mast/Spars/Sails/Standing and Running Rigging (if racing risk required)
Outboard Motor
Personal Effects (Maximum £75 any item unless specified)
Third Party Liability level
Total Sums Insured
Specify currency
Other Currency
When do you require cover to commence
My present policy is with
Years Insured
Current No Claims Bonus entitlement (evidence required)
How did you find us?
Please Specify
Any Comments you wish to add?
Completion Notes: Many craft built before 1999 do not have a serial number. If this information is not readily to hand, or is not displayed on a plaque next to the dash panel, then the vessel may not have been allocated a production or serial number. Over time, Marine Engines are often repainted to keep them looking smart. This means that it may not be possible to provide us with the engine serial number as successive layers of paint can easily obliterate the details. Please be aware that if you do not provide details of serial numbers of outboard engines, this will affect theft coverage. A vessel does not have to be lifted out of the water to be laid up for winter. Many craft are “winterised” afloat. This usually involves draining down water systems and engines, as well as liberal use of antifreeze in drainpipes, closed sea-cocks, etc. The period that the craft is “winterised” and left “for the winter” is the laid up period that is required. The Hull/Machinery Sum Insured is the value of the craft including all of the standard kit (e.g. Cookers, soft Furnishings, etc.). If you have just bought the craft, this is invariably the price you have just paid. Any additional items that you add to the craft should be listed separately under the headings of “Personal Effects” and “Navigation Equipment”, Etc. The Declaration is vital to our acceptance of the proposal form. Without a properly completed and signed proposal form in hard copy format, we will be unable to pass the form onto an insurance provider and cover will not be provided.
Declaration
Insurance on any vessel declined or Special Terms imposed	No Yes
Ever been charged with or convicted of any offence involving dishonesty	No Yes
Any accident or losses in respect of any vessel	No Yes
Are you the sole owner of the vessel	No Yes
Is the vessel the subject of any mortgage or financial agreement	No Yes

I declare that to the best of my knowledge and belief, the information given to you on this form is true in every respect. I also declare that if anything on this form was entered by another person, he/she acted as my agent for this purpose. I agree that this proposal and declaration shall be the basis of the Contract between me and the Northernreef Insurance Company SA (the company).. Note: Submitting this form does not bind the proposer to complete this insurance. The Company reserves the right to decline any proposal. The Proposer should keep a record of all information supplied to the Insurer for the purpose of entering into the Contract, and a copy of this Proposal will be supplied on request, within a period of three months after completion. Edward William Marine Services SL is a Spanish Registered Insurance Agent and as such is not authorised or Regulated by the UK Financial Services Association and is not covered for compensation under the UK Financial Services Compensation Scheme (FSCS)

I agree to the above declaration
Signed:
Date:

SEVERE STORM/HURRICANE STATMENT
Must Be Completed
Name of Insured:
Boat Name/type:
What arrangements have you made and what will you made to safeguard your boat in the event of a Named Hurricane or Tropical Storm warning being issued? Please be specific and state what additional anchors/lines will be deployed, item removed etc.
Where will your vessel be kept in such an event
What alternative arrangements have you made if your original plan becomes unworkable? Example: if you are away from your home port.
Who other than yourself will be responsible for preparing your vessel for a storm
Have you ever had to prepare for a hurricane before
When and where?
It is understood and agree that in the event of a named Hurricane or Tropical Storm warning, I/We will make every reasonable effort to secure the above vessel and/or it's equipment, including but not limited to removing/stowing of sails, bimini canvas, loose items, outriggers and antennas.	I Agree.
Signed
Dated

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Marine Insurance Application Form

Particulars of Vessel

Particulars of Engine(s)

Are the following areas fitted with an automatic or remote fire extinguishing system?

State the number of fire extinguishers carried

Gas System

Cruising Range

Details of Moorings

Sums to be Insured

Completion Notes:

Declaration