Paul Lynch & Associates, Inc.
3388 NE Sugarhill Avenue, Stuart, FL 34994
Tel: 772-232-9371 / FAX: 772-232-2522

Vessel Owners Application
 
Applicant Information:
Name:
Address:
Address:
City:
State:
 ZIP:
County:
Occupation:
Phone:
FAX:
E-Mail:
Producer Information:
Name:
Address:
Phone:
FAX:
Lienholder Information:
Name:
Address:
City:
State:
ZIP:
Vessel Information:
Name:
Equipment:
Bilge Pump Radar Engine Alarm
Cooking Stove Loran/Direction Finder Life Raft
Fume Detector Ship to Shore radio Other:
CO2/Halon System SATNAV/OMEGA
Fire Extinguishers Aux Generator Gasoline
Anti-Theft Devices Aux Generator Diesel
Depth Sounder EPIRB
Sonar GPS
Primary Power: Sail Outboard Inboard/Outdrive Other
Type of Hull: Sailboat Performance Runabout
Hull Material: Wood Metal Fiberglass
Fuel Tank: Metal Fiberglass
Year:
Length:
Purchase Date:
Present Value:
Max Speed:
Registration #:
Hull ID No:
Manufacturer:
Model:
Storage City:
Storage County:
Storage State:
Tenders or Dinghies:
Anti-Theft Precautions:
Waters to be navigated:
Coverages: Sums Insured
Hull - Physical Damage
Tender / Dinghies:
Liability Coverage
Crew Liability:
Owner / Operator M&C:
Medical Payments:
Commercial Passenger Lia:
Uninsured Boater:
Trailer:
Personal Property:
Non-Emergency Towing:
Other:
Engine Information:
ENG H.P. Gasoline Diesel Year Date Purchased Purchase Price Present Value
1
2
3
Manufacturer / Model Serial Number
1
2
3
Trailer Information:
Year:
 Date Purchased:
 Purchase Price:
 Present Value:
Manufacturer/Model:
 Serial Number:
Details of previous vessels owned:
Operator Information: (Always list insured as operator #3)
# Name Date of Birth Driver License # DL State Social Security # USCO/Power Squadron Certificate
1
2
3
# Auto Violations / Suspensions in Last 5 Years Years of Boat Ownership
1
2
3
General Information:
# Explain all YES answers in remarks field YES NO Remarks
1 Is the boat chartered to others with captain?
2 Is the boat chartered to others without captain?
3 Is the boat used for racing?
4 Is the boat used for skiing or diving?
5 If the boat is used for fare paying passenger charters, what is the average number of passengers per trip:
Number of trips per year:
6 Is the boat used commercially or for business purposes?
7 Does the applicant employ a paid crew, if yes how many?
8 Was any operator involved in a marine loss in the last 10 years (insured or not)?
9 Was any coverage declined, canceled, or non-renewed during the last 5 years?
10 Date of survey: Type of survey: Out of water In Water
PLEASE READ BEFORE SUBMITTING APPLICATION:
  1. This application will be incorporated in its entirety into any relevant policy of insurance where insurers have relied upon the information contained herein.
  2. Any misrepresentations in this application for insurance, will render insurance coverage null and void from inception. Please therefore check to make sure that all questions have been fully answered and that all facts material to your insurance have been disclosed, if necessary, by a supplement to the application.
  3. A photograph of the vessel is required to be submitted with this application. Our office will contact you regarding sending the photo to us and obtaining your signature on the final application.

NOTICE:

The normal procedure used by the company to evaluate applications may include obtaining an investigation consumer and credit report involving information on such things as charter, general reputation, personal characteristics and mode of living. Information on the nature and scope of such a report, if one is made, will be given to you upon request.
Signature:
Date: