SUPPLEMENTAL APPLICATION – MARINE - Polestar Insurance LLC

Thank you!

NEXT: PLEASE FILL OUT THE SUPPLEMENTARY APPLICATION BELOW

MARINE INSURANCE APPLICATION
Name *
First
Last
Home Address
Date of Birth
Social Security #
Company name (Named Insured)
Location Address
Mailing Address
Section 3 BUSINESS DETAILS
What is the zip code of the vessel mooring location?
Describe all ways in which the vessel is used.
What year did the applicant purchase or establish this business?
Has any company cancelled, non-renewed or refused to offer insurance (including under any prior names)?
YES
NO
If yes, describe.
Are any of the vessels homemade or have any of the vessels, engines or operating equipment been modified or altered from original, stock condition?
YES
NO
If yes, describe.
Is any vessel currently being held for sale?
YES
NO
Has anyone involved with this business ever been convicted of a felony?
YES
NO
List the date of Loss, write a detailed description of the Loss and Amount Paid
Has the applicant or business operated under any other name?
YES
NO
If yes, describe.
What year was this business incorporated under this name?
Describe the owner's experience with this type of Operation and vessel usage?
Who is your current insurance carrier?
How many days per year is the vessel(s) used commercially?
Does the owner employ a Captain, Crew, or other employees to Operate or Maintain the vessel(s)?
YES
NO
If yes, number of crew.
Is any vessel used as a liveaboard?
YES
NO
Do individuals stay onboard overnight?
YES
NO
Is swimming, snorkeling, SCUBA, or diving allowed from any vessel?
YES
NO
If yes, describe.
Are the vessels seaworthy and fit for their intended use?
YES
NO
If yes, describe.
Do you lease a vessel from or to another party?
YES
NO
If yes, describe.
List and describe any other insurance in force for this business.
Is there any affiliation with a camp or youth group?
YES
NO
If yes, describe.
Do you have a relationship with any legal entity, other than a marina or yacht club that will require legal protection as an Additional Insured?
YES
NO
If yes, describe the relationship and their ability to control any aspect of your business.
Additional Insured Name
First
Last
Additional Insured Address
OPERATOR/CAPTAIN INFORMATION IS REQUIRED FOR: CHARTER, CHARTER – GUIDE, OWNER/OPERATOR, BOAT SCHOOL & COMMERCIAL FISHING RISKS
SECTION 4 PRIMARY OPERATOR/CAPTAIN INFORMATION
Fill out the boxes below
Full Name *
First
Last
Date of Birth
Drivers License #
License State:
Year USCG Licensed:
Describe and provide the month/year for all Motor Vehicle Violations and Accidents in the last 3 years: (If none, write none.)
Describe and provide the month/year for any marine losses that have occurred personally or for any vessel when this operator was in control. (If none, write none.)
Does the operator take any medicine or substance that could impair physical or cognitive ability? If yes, describe. If none, write none.
Outline experience below for the last 3 vessels owned or operated:
Vessel Year, Builder, Length, From (Mo/Yr) To (Mo/Yr), Owned(YES or NO), Operated (YES or NO)
Section 5 CREW COVERAGE INFORMATION
Describe training and safety courses taken:
If the Captain/Skipper is the owner, what percentage of the charters will they act as the Charter Captain?
Has the operator sustained any injuries that required a doctor visit, hospitalization, or professional care in the last 5 years?
YES
NO
If yes, describe.
Does the operator have any known health problems?
YES
NO
If yes, describe.
Does the operator have health care insurance?
YES
NO
Additional Remarks:
Section 10 VESSEL INFORMATION
Please complete an additional sheet for each Operator/Captain.
Vessel Usage:
IN SEASON LOCATION
Facility/Marina Name:
Facility/Marina Address:
Is any vessel kept on a mooring buoy?
YES
NO
LAY-UP/STORAGE LOCATION
Lay-Up Dates:
From:
To:
Lay-Up Type:
Ashore
Afloat
On a Lift
Lay-Up Address:
NAVIGATION
Navigation Area Desired:
If coastal, # of miles offshore:
1
5
25
50
100
200
VESSEL #1
Year
Length
Manufacturer
Model
Hull Material:
Hull ID# (HIN):
# of Engines:
Total HP:
Hull Type:
Propulsion:
Engine Serial #’s: (if outboard)
Safety Equipment:
EPIRB
Life Raft
CO/Smoke Detector
Fixed Fire Suppression
GPS
Depth Finder
Total Value (Vessel w/Engines):
Liability Only Coverage?
YES
NO
Loss Payee Name & Address
Trailer Year:
Manufacturer:
Value:
VESSEL #2
Year
Length
Manufacturer:
Model:
Hull Material:
Hull ID# (HIN):
# of Engines:
Total HP:
Hull Type:
Propulsion
Engine Serial #’s: (if outboard)
Safety Equipment:
EPIRB
Life Raft
CO/Smoke Detector
Fixed Fire Suppression
GPS
Depth Finder
Total Value (Vessel w/Engines):
Liability Only Coverage?
YES
NO
Loss Payee Name & Address:
Trailer Year:
Manufacturer:
Value:
In areas where a wind deductible applies, the hull value needs to be greater than the wind deductible. The windstorm deductible will be the maximum of 2 times the stated deductible or 5% of the unit value, whichever is greater.
PRIMARY COVERAGES
VESSEL DEDUCTIBLE (Rental & Boat Club minimum $1,000, all others minimum $500.)
$500
$1,000
1%
2%
3%
4%
5%
10%
20%
Choice 13

ability Lay-Up 2

WATERCRAFT LIABILITY
$25,000
$50,000
$100,000
$300,000
$500,000
$1,000,000
UNINSURED WATERCRAFT (not available on Rental)
$25,000
$50,000
$100,000
$300,000
$500,000
$1,000,000
MEDICAL PAYMENTS (not available on Rental)
$1,000
$2,500
$5,000
$10,000
$15,000
$20,000
$25,000
POLLUTION
$25,000
$300,000
$854,000
PERSONAL EFFECTS** (not available on Rental & Boat Club)
$1,000
$2,500
$5,000
$10,000
$15,000
$20,000
$25,000
ADDITIONAL COVERAGES
CHARTER
Crew Liability
Fishing Equipment***
Towing
Business Interruption
Liveaboard
Preferred Charter
Shoreside Liability Extension
Guest Passenger Liquor Liability
Premises Liability*
Slip & Mooring*
RENTAL
Watersport Liability
Permitted Rental Captain
Permitted Operator – Pleasure Use
Premises Liability*
Slip & Mooring*
BAREBOAT CHARTER
Towing
Captained Charter
Premises Liability*
Slip & Mooring*
CHARTER – GUIDE
Fishing Equipment***
Towing
Business Interruption
Preferred Charter
Shoreside Liability Extension
Premises Liability*
Slip & Mooring*
OWNER/OPERATOR
Towing
Watersport Liability
Business Interruption
Cargo Liability
Liveaboard
Premises Liability*
Slip & Mooring*
BOAT CLUB
Watersport Liability
Permitted Operator – Pleasure Use
Premises Liability*
Slip & Mooring*
COMMERCIAL FISH
COMMERCIAL FISH
BOAT SCHOOL
Captained Charter
Premises Liability*
Slip & Mooring*
Additional Remarks:
Paragraph Text
98550