HAML — Large Yacht Insurance Intake

Applicant Information

Personal details and contact information for the named insured.

Personal Details

Name Insured *

Company Name (if applicable)

Email Address *

Phone Number *

Date of Birth

SSN # (optional)

Driver's License #

DL State

Occupation

If Corporate — Beneficial Owner

Address

Street Address

City

State

Zip Code

Additional Questions

Does the insured reside in Florida 12 months a year?

Is the Corporation a Single Asset, not-for-profit entity?

Vessel Information

Details about the yacht to be insured.

Vessel Details

Manufacturer / Builder

Model

Length (ft)

Year

Vessel Name

Hull Identification Number (HIN)

State Registered?

Registration #

Vessel Flag

Date Purchased

Purchase Price

Vessel Use

Private Registry Racing Commercial Registry Captain Charter

Engine & Equipment

Engine specifications, navigation equipment, and survey details.

Safety Equipment & Security

No. of Handheld Fire Extinguishers

Current Marine Survey

Is there a current marine survey on file?

Survey Type

Afloat Out of Water / Dry Dock

Year of Survey

Name of Surveyor (SAMS or NAMS)

Primary Operator & Boats Previously Owned

Experience of the primary operator and prior vessel ownership history.

Primary Operator

Primary Operator Name *

Date of Birth

Driver's License #

State

Married?

Spouse Operates Vessel?

Years of Boating Experience

Boating Courses

Ownership Experience (types/sizes of boats previously owned)

Operation Experience (waters navigated, passages made)

Loss History & Yacht Tender

Claims history, driving record, and tender / personal watercraft details.

Loss History & Driving Record

Has there been more than one loss?

Loss Date

Loss Amount

Cause of Loss

Loss History Notes

Have you ever been convicted of a Felony or DUI?

Please provide details

Any tickets or accidents on your driving record in the past 3 years?

Please provide details

Yacht Tender / Personal Watercraft (may be insured for additional premium)

Do you have a yacht tender or personal watercraft to include?

Tender Manufacturer

Engine Manufacturer

Model

Hull Year

No. of Engines

Engine Year

Length

Engine HP (each)

Top Speed

Hull Identification # (HIN)

Engine Serial Number

Insurance Coverages Requested

Enter desired coverage amounts and deductibles for each section.

Vessel Hull & Machinery

Amount of Insurance

Deductible

Named Windstorm Deductible

Personal Effects

Amount of Insurance

Deductible

Tender & Outboard

Amount of Insurance

Deductible

Fishing Equipment

Amount of Insurance

Deductible

Liability (P&I)

Amount of Insurance

Deductible

Uninsured Boaters

Amount of Insurance

Deductible

Medical Payments

Amount of Insurance

Deductible

Crew Liability

Amount of Insurance

Deductible

Any notes for Named Windstorm Deductible

Mooring & Navigation

Where and how the vessel is stored and navigated.

Primary Mooring Location (Summer)

Address (Street, City, State, ZIP)

Location Name (Marina / Storage / Residence)

Storage Type

Secondary Mooring Location (Winter)

Address (Street, City, State, ZIP)

Location Name (Marina / Storage / Residence)

Storage Type

Navigation Areas

Other Navigation Areas

Layup Period

Layup Start Date

Layup End Date

Layup Location

Ashore Afloat

Lienholder & Additional Insured

Lienholder Name

Lienholder Address

Additional Insured Name

Additional Insured Address

Other Information & Questions

Underwriting questions, insurance history, and vessel activities.

Other Information

Was any insurance declined, canceled or non-renewed in the last 5 years?

Has the vessel been involved in a loss previously or deemed a Total Loss?

Has the boat or engines been modified or altered from their stock condition?

Does the loan value exceed 90% of the purchase price?

Is the vessel full time live-aboard?

Is a permanent affixed anti-theft tracking device installed on this vessel?

Does the insured own a residence outside of Florida?

Is the vessel used commercially or for business purposes?

Is the vessel ever chartered to others with a captain and crew?

Is the vessel used to undertake dive boat charter activities?

Please provide further details for all YES responses above

Captain & Crew

Do you employ a paid captain or crew?

Number of Full-Time Crew

Number of Part-Time Crew

What are their duties?

Max / Avg Passengers Per Trip (fare-paying vessels)

Number of Trips Annually

Insurance History & Broker Details

Current Insurance Provider

Current Marine Insurance Broker / Agent

Current Premium

No. of Marine Insurance Companies (past 5 yrs)

Prior Company #1 — Name | Type of Policy | Dates Covered

Prior Company #2 — Name | Type of Policy | Dates Covered

Additional Questions

Do you require Jones Act and / or Crew Coverage?

Are there any other businesses (other than boating) that you or the insured entity are involved in?

Have you or any principal of the business declared bankruptcy in the past 5 years?

Do you engage in fishing tournaments, races, or any special events?

Do you have a hurricane plan?

Do you use a hurricane haul-out facility?

Have you or any captain / crew ever been subject to a suspension or revocation of USCG or other licenses?

Vessel Activities & Features

Are any of your vessels equipped for diving, parasailing, or water sports?

Is there a written safety manual or training provided for crew and passengers?

Are there regular maintenance logs kept for all vessels?

Do you offer off-the-boat activities?

Please describe off-the-boat activities

Applicant Information

Vessel Information

Engine & Equipment

Primary Operator & Boats Previously Owned

Loss History & Yacht Tender

Insurance Coverages Requested

Mooring & Navigation

Other Information & Questions

Application Submitted!