Please complete/check this form, sign it and then return to your agent/broker. The information you provide is an important part of any subsequent insurance cover, so please ensure it is accurate.

Section 1: Owner

Name

Address

Date of Birth

Nationality

Telephone Number

Email

Have you had any marine hull or liability accidents or claims in last 5 years? If ‘Yes’ then please provide details
YesNo

Have you ever been refused insurance or had an insurer cancel or apply special conditions or been convicted of any fraud or dishonesty If ‘Yes’ then please provide details
YesNo

Section 2: Vessel Details

Vessel Name Registration / ID no.
Type of Vessel Make / Model
Year Built Length(ft.)
Hull Material Maximum Design Speed (MDS) in knots
Engine(s) Power (HP)
Age of Engine(s) Fuel
Serial Number Last Dry Dock

Section 3: Operator

1. Full Name Age
Years Sailing
License / Formal Qualifications
(e.g. Thai Captain Class 1, RYA Yachtmaster, AYA Coastal Skipper)

2. Full Name Age
Years Sailing
License / Formal Qualifications
(e.g. Thai Captain Class 1, RYA Yachtmaster, AYA Coastal Skipper)

Section 4: Territorial Limits & Operation

Navigation limits required

Normal berth/storage when vessel is not being used?

Section 5: Usage

Private & Pleasure

Private racing - please detail events (NB – If racing cover is agreed by underwriters this will be in respect of private racing only where the owner receives no reward from a third party for the use of the vessel.)

Charter with skipper/crew provided by the owner

Will charter include racing? Please detail events (NB – If such cover agreed by underwriters this will be with a skipper provided by owner i.e. vessel is not on bareboat charter.)

Lay up: Please declare period and expected location (Please state whether in-water or on hard-stand)

Section 6: Vessel value

Vessel value
Currency Amount
Limit of Liability
Currency Amount
Being the current actual market value of the vessel, assuming a willing seller and a willing buyer, with all the gear and equipment that would normally be sold with the vessel. Should not include tender/dingy/outboard or personal effects. These values should be declared separately.

Section 7: Declaration

I declare the above particulars and answers are correct and complete in every respect to my knowledge and belief. I confirm that I have never been convicted of any fraudulent or criminal activity. I agree that this proposal and declaration shall form the basis of the contract of insurance between myself and insurers if a policy is issued.