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1 800 223 9998
1 714 739 3177
FAX us at
1 714 739 3188
If less than 100%, Please explain:
If yes, send us a copy so we can make sure
you’ve incorporated the latest Release Law.
If yes, we will send you an
in water supplemental application.
you want coverage for Paid Crew while they are in the water?
If yes, we will send you an in water supplemental application.
DESCRIPTION OF BOAT
* MISREPRESENTATION OR
ANY OF THE ABOVE
MAY VOID COVERAGE *
of Understanding (This box must be checked)
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result in your policy being voided or rescinded at any time,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
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