Marine Proposal Form

YACHT APPLICATION

(required if policy is in a company name)

Coverages will not be provided unless requested hereon

Coverage

Sum Insured

Hull - Physical Damage

Tender/Dinghy

Personal Property

Trailer

Medical Payments

Liability Coverage

Crew Liability

Owner Operator M&C

Commercial Passenger Liability

Uninsured Boaters

Breach Of Warranty (For Loss Payee Only)

Non-Emergency Towing

Give Details

Vessel Information

Full Address
(you may attach an itinerary – please note extended navigation requires supplementary sheet)
(including co-ordinates if known)

Engine/Outboard Motor Information

Trailer Information

Operators

(Always List Insured As Operator #1) All Operators Must Be Detailed – Use Separate Sheet If Necessary Please Note This Operators Information Consists Of Three Parts (A, B & C)

Part A

Part B

Part C

 

Applicable in California
For your protection, California law requires the following to appear on this form:

Any person who knowingly presents false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

California Insurance Frauds Prevention Act 1871.2

Applicable in Florida and Idaho
Any person who Knowingly and with the intent to injure, Defraud, or Deceive any Insurance Company Files a Statement of Claim Containing any False, Incomplete or Misleading Information is Guilty of a Felony* *In Florida – Third Degree Felony

Applicable in Indiana
A person who knowingly and with intent to defraud an insurer files a statement of claim containing false, incomplete, or misleading information commits a felony.

Applicable in Nevada
Pursuant to NRS 686A.291, any person who knowingly and willfully files a statement of claim that contains any false, incomplete, or misleading information concerning a material fact is guilty of a felony.

Applicable in New Hampshire
Any person who, with purpose to injure, defraud or deceive any insurance company, files a statement of claim containing any false, incomplete or misleading information is subject to prosecution and punishment for insurance fraud, as provided by RSA 638:20.

Applicable in New Jersey
Any person who knowingly and with the intent to defraud any insurance company or other persons, files a statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact, material thereto, commits a fraudulent insurance act, which is a crime, subject to the criminal prosecution and civil penalties

Applicable in New York
Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact, material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

Applicable in Ohio
Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

Applicable in Oklahoma
WARNING: Any person who knowingly and with the intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony

Applicable in Pennsylvania
Any person who knowingly and with intent to injure or defraud any insurer files an application or claim containing false, incomplete or misleading information shall, upon conviction, be subject to imprisonment for up to seven years and payment of a fine of up to $15,000.