DIVE BOAT MARINE INSURANCE - APPLICATION

 

 

  Policy Period is from 12:01 AM July 22, 2017 through 12:01 AM July 22, 2018  
     
  APPLICATIONS MUST BE RECEIVED IN OUR OFFICE BY July 22, 2017.
THERE IS NO GRACE PERIOD.
ALL OTHERS WILL BE EFFECTIVE THE DATE RECEIVED.
 
     
  Underwritten by a U.S. Rated A++ XV Insurer  
  CONTACT US!  
 

Have questions?
Call us at
1 800 223 9998
or
1 714 739 3177

FAX us at
1 714 739 3188

 

BUSINESS INFORMATION

 
Requested Policy Period, from:   To 07/22/2018   (MM/DD/YYYY)
Application Type:   New Renewal
PADI No.
Legal Business Name:
DBA:
Corporation
Who are the shareholders?
Partnership

  Who are the partners?
Sole Proprietor    
Other, please explain:
       
Street Address 1:
Street Address 2:
City:   State/Province:
Country:   Zip Code:
 
Phone:   FAX:
E-Mail:
E-Mail 2:
Web Site:
   
 

POLICY INFO

 
Excess Liability Coverage (Primary limit $1,000,000) No  1M  2M  3M  4M 9M
Any Boat claims? Yes  No
If yes, please list including dates and amounts:
Current Insurance Company:
Has a marine insurance policy ever been cancelled or non renewed?    Yes  No
   
 

BOAT USAGE

 Waters to be navigated, please specify:

OR check one:    Caribbean  U.S. East Coast  U.S. Gulf Coast  U.S. West Coast  Great Lakes  Hawaii

 
Name of Captain:
Is Captain owner of boat? Yes  No
   
Certified for Maximum Number of Passengers:
Percentage of trips for diving charters: %

If less than 100%, Please explain:

Coast Guard Approved? (Mandatory in U.S.): Yes  No
    Registry No.:   
Do passengers remain on board for more than one consecutive 24-hour period? Yes  No
Do you use a waiver or release of liability for all passengers? Yes  No

If yes, send us a copy so we can make sure you’ve incorporated the latest Release Law.

   
Do you want coverage for passengers while in the water? (Group Professional Liability) Yes  No

If yes, we will send you an in water supplemental application.

   
Do you have an oxygen kit on board? Yes  No
Do you have a compressor on board? Yes  No
Layup Period From:     (MM/DD/YYYY)          To:     (MM/DD/YYYY)
   
 

CAPTAIN AND CREW SCHEDULE

 
Name Duty FT/PT Do they have Professional Liability Insurance? PADI Number
FT  PT Yes  No
FT  PT Yes  No
FT  PT Yes  No
FT  PT Yes  No
FT  PT Yes  No
FT  PT Yes  No
         
Has any crew had decompression sickness or received hyperbaric treatment in the last three (3) years? Yes  No
Do you want coverage for Paid Crew while onboard the vessel? Yes  No

Do you want coverage for Paid Crew while they are in the water?
If yes, we will send you an in water supplemental application.

Yes  No
Do you require all instructors and divemasters on board your vessel to carry professional liability insurance? Yes  No
Do you require your Captains to remain on the boat at all times? Yes  No
   
 

DESCRIPTION OF BOAT

 
Name of Vessel: Manufacturer:
Year Built:   (YYYY) Serial No.: Model:
Length Overall: Material of Hull: Maximum range:
Engine Make: Total Horsepower:
Date of last survey:   (MM/DD/YYYY) Have recommendations been completed? Yes  No
Type of propulsion: Inboard Outboard Sail Inboard/Outboard Other If other, please specify
Protective devices (automatic firefighting systems, etc):
Purchase Price: $   (Do Not include a Dollar sign or comma's. Example: 7000.00)
Date of Purchase:       (MM/DD/YYYY)
Hull Market Value
(Amount to be insured):
  (Do Not include a Dollar sign or comma's. Example: 7000.00)
Are maintenance logs kept? Yes  No Are copies stored on land? Yes  No
 
 

DINGY/TENDER

None
 
Manufacturer:     Age: (Years) Dingy Length : (Feet)
Value:   (Do Not include a Dollar sign or comma's. Example: 7000.00)
 
 

TRAILER

None
       
Manufacturer:     Year Built:   (YYYY)
Value: $    (Do Not include a Dollar sign or comma's. Example: 7000.00)
Serial No.:        
       
 

LOSS PAYEES

None
 
Payable To:
Address:
   
 

ADDITIONAL INSUREDS (No Charge)

   
1. Employees are automatically covered under your store or resort operator's policy (does not include Professional Liability).
2. Divemasters and Instructors may not be added as additional insureds.
3. Owners, officers and directors of your business are automatically covered under your policy and need not be added as additional insureds (does not include Professional Liability).

 

  As per existing policy (if renewing) New list of Additional Insureds No Additional Insureds  
   

 

Information for each Additional Insured is required as follows:
Name Address City State Zip
 
 

ADDITIONAL REQUIRED INFORMATION

 
  Please indicate how you will be sending us the following information:
   
  Email to diveboat@diveinsurance.com
    or
  FAX to (714) 739-3188
   
    Current Survey
    Certificate of Inspection if over six (6) passengers
    Captains License (Front and Back)
    Photo of Boat
   
 

* MISREPRESENTATION OR CONCEALMENT OF ANY OF THE ABOVE
MAY VOID COVERAGE *

 

Statement of Understanding (This box must be checked)

By checking this box ...

This is not a binder of insurance coverage, and does not bind the insurer or Vicencia Buckley, a division of HUB International, until approved by the insurer and a premium is paid by the applicant and all required documents are received.

We (I) acknowledge that this policy does not cover in water accidents and that we (I) have or require Professional Liability in place for in water accidents. No coverage is provided under this policy for Liquor Liability.

It is your duty to correct any wrong information and to complete any omitted information on this application. Concealment, misrepresenting, or stating falsely on this application may result in your policy being voided or rescinded at any time, even after a loss.

 

Person Completing this application

Name :

Title :

 
 

PAYMENT INFORMATION

 

Upon receipt and review of the completed application, Vicencia & Buckley, a division of HUB International will provide your with a total premium for your approval before coverage is placed. Upon your acceptance of the policy and premium, credit card information can be provided to Vicencia & Buckley, a division of HUB International or a check/money order mailed. Premium Financing is also available.

 

COMMENTS

 
 

 

 
License #: 0757776
Copyright Vicencia & Buckley, A Division of HUB International Insurance Services, Inc.