Owner(s) Full Name(s) *

Date of Birth(s) *

Full Address *

Phone Number *

Email Address *

Number of years experience *

Boating qualifications *

Vessel make & model *

Vessel name *

Length *

Year built *

Vessel material *

Country of registration *

State of registration (if applicable)

Make of engine *

HP of engine *

Year of engine *

Fuel type *

Petrol     Diesel

Maximum design speed (knots) *

Name(s) of cruising associations or clubs you are a member of (if applicable)

Rigging age (if applicable)

Year of last survey
(if possible please send a copy when returning this form to us)

Use (choose one)

Is your vessel used for racing?

Yes     No

If yes, please specify the type of racing and value of mast, spars, sails and rigging (if applicable)

Currency to quote in *

Purchase date (if applicable)

Purchase price (if applicable)

Vessel, machinery, gear and equipment current sum insured *

Tender Value $

Outboard Value $

Personal Effects Value $

Other Value (please list items and their value to be covered)

Mooring location *

Type of mooring *

Lay-up location (if applicable)

Lay-up dates (if applicable)

Cruising area for the 12 month insurable period *

No claims bonus entitlement

Yes     No

Have you had any claims in the past 5 years?

Yes     No

If yes, please specify the year of claim, details of the claim and amount paid out by the insurer

Finance Interest. Please specify the Finance Company name, address and agreement number (if applicable)

Current insurer (if applicable)

Renewal Date (if applicable)

How did you hear about us *

Any other information (if applicable)