Charter Lakes Insurance Application PDF Details

Charter Lakes Insurance Application is a website that provides free insurance quotes. We help individuals find the best rates for their individual needs. Whether you are looking for life, health, or auto coverage our mission is to deliver quality service with competitive prices to all of our clients. Our team understands the importance of finding the right policy and providing peace-of-mind for your family's financial future. We will work with you through every step of the process; answering any questions that you may have along the way about what plan fits your needs best.

Here's some facts that will help you understand how much time it will take to finish the charter lakes insurance application.

QuestionAnswer
Form NameCharter Lakes Insurance Application
Form Length2 pages
Fillable?Yes
Fillable fields263
Avg. time to fill out26 min 35 sec
Other namescharter insurance application, charter spectrum repair insurce, what is a dte insurance form, acord 82 watercraft application

Form Preview Example

 

 

3940 Peninsular Dr SE, Suite 100, Grand Rapids, MI 49546-6107

(800) 879.2248 FAX (616) 975.0670

 

 

 

 

 

 

 

 

 

 

Website: www.charterlakes.com

 

 

 

 

 

 

E-mail: charterlakesinfo@ajg.com

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WATERCRAFT INSURANCE APPLICATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PERSONAL INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

REGISTERED OWNER OR LEASEE – NAME(S)

 

 

 

 

 

 

 

 

 

 

DOING BUSINESS AS

 

 

 

 

 

 

 

MARITAL STATUS

 

 

RESIDENCE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MARRIED

SINGLE

 

OWNED

RENTED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PHYSICAL ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CITY

 

 

 

 

 

 

 

 

 

 

 

 

State

 

 

ZIP

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MAILING ADDRESS (IF DIFFERENT THAN PHYSICAL ADDRESS)

 

 

 

 

 

 

CITY

 

 

 

 

 

 

 

 

 

 

 

 

STATE

 

ZIP

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HOME PHONE

 

 

 

 

 

 

 

 

 

CELL PHONE

 

 

 

 

 

 

 

 

 

FAX NUMBER

 

 

 

 

 

 

 

 

 

EMAIL ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DRIVERS LIC. NO.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DATE OF BIRTH

 

 

 

OCCUPATION

 

 

 

 

 

 

 

S.S. #

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WATERCRAFT / TRAILER

/ DINGHY INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

TYPE OF VESSEL

 

 

CRUISER / MOTOR YACHT

SAILBOAT

 

FLATS SKIFF

 

BASS BOAT

DRIFT BOAT

CENTER CONSOLE

 

 

 

 

 

SPORTFISH

 

 

 

 

 

 

 

PONTOON

 

AIRBOAT

 

 

 

 

OPEN FISHING

TRAWLER

RUNABOUT

 

 

 

YEAR

 

LENGTH

 

 

 

MANUFACTURER

 

 

 

 

 

 

 

 

 

 

 

 

 

MODEL

 

 

 

 

 

 

 

HULL MATERIAL

BEAM

WEIGHT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME OF YACHT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

REG./DOC. NO.

 

 

 

 

 

 

 

 

 

 

 

 

HULL I.D. NO.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PURCHASE DATE

 

 

 

 

 

 

 

 

 

 

PURCHASE PRICE

 

 

 

 

NEW REPLACEMENT COST

 

 

 

 

 

DATE OF LAST SURVEY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MACHINERY

 

GAS

 

YEAR OF ENGINE

 

 

MFG AND MODEL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NO. OF ENGINES

 

H.P. EACH

 

 

 

 

DIESEL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MAX SPEED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SERIAL NO.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TYPE OF DRIVE

OB

 

IB

IO

 

 

 

JET DRIVE

SURFACE DRIVE

SERIAL NO.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SERIAL NO.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EQUIPMENT

 

 

GPS / SAT NAV / LORAN

 

 

RADAR

 

 

 

LIFE RAFT

 

 

 

 

 

HIGH WATER ALARM

 

 

TRAILER BALL OR AXLE LOCKS

 

 

 

 

VHF / SHIP TO SHORE

 

 

CHART PLOTTER

 

 

AUTO CO2 OR HALON

 

 

CO DETECTOR

 

 

ANTI THEFT DEVICE

 

 

 

 

 

 

 

 

 

 

DEPTH FINDER

 

 

 

 

 

AUXILIARY GENERATOR

FUME DETECTOR

 

 

OB / OUTDRIVE LOCKS

EPIRB

 

 

 

 

 

 

 

TRAILER

 

 

YEAR

 

 

 

 

MANUFACTURER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SERIAL NO.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DINGHY

 

 

 

 

 

YEAR

 

 

 

 

 

LENGTH

 

 

 

MANUFACTURER

 

 

 

 

 

 

SERIAL NO.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DINGHY ENGINE

 

YEAR

 

 

 

 

H.P.

 

 

 

 

 

MANUFACTURER

 

 

 

 

 

 

SERIAL NO.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

COVERAGE INFORMATION (Client must complete)

 

 

 

 

 

 

 

 

 

 

 

 

HULL VALUE REQUESTED (inc. engine(s) & electronics)

$

 

 

 

 

 

 

 

 

 

 

 

 

MEDICAL PAYMENTS

 

YES

NO

 

 

 

HULL DEDUCTIBLE REQUESTED

 

 

 

 

 

 

 

 

 

 

1%

2%

3%

4%

 

 

5%

 

UNINSURED BOATERS

 

YES

NO

 

 

 

LIABILITY LIMIT REQUESTED

 

 

 

 

 

 

 

 

 

 

 

 

$100,000

$300,000

$500,000

 

TOWING

 

 

 

 

 

 

YES

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$1,000,000

 

OTHER

$

 

 

 

 

 

DINGHY VALUE (inc. engine)

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PERSONAL EFFECTS & FISHING EQUIP.

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

TRAILER VALUE

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAVIGATION AND STORAGE INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

OPERATING PERIOD (ALL USES OF VESSEL)

 

 

DESCRIBE ALL WATERS NAVIGATED AND MAXIMUM MILEAGE OFFSHORE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YEAR ROUND

 

 

 

SEASONAL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MOORING LOCATION

 

 

 

MARINA

 

 

 

 

 

 

 

NAME OF MARINA (IF APPLICABLE)

 

 

 

 

 

 

 

 

 

 

SLIPPED

 

TRAILERED

 

 

 

 

 

PRIVATE RESIDENCE

 

 

 

 

 

 

 

 

 

 

 

 

TYPE OF MOORING

 

DRY STORAGE

 

MOORING

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OTHER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LIFT

 

OTHER

 

 

 

 

COUNTY OF MOORING LOCATION

 

ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CITY

 

 

 

 

 

 

 

 

 

STATE

 

 

ZIP

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LAY-UP LOCATION

 

VESSEL IS STORED (DURING SEASONAL LAY-UP)

 

 

 

 

 

 

 

WARRANTED LAY-UP PERIOD (MM/DD)

Ex.

11/1 to 4/1

 

 

 

 

 

 

 

ASHORE

 

 

 

 

AFLOAT

 

 

 

 

 

 

 

 

 

FROM

 

 

 

TO

 

 

 

 

 

 

 

 

 

 

 

 

NAME OF LAY-UP LOCATION

 

 

 

 

 

ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CITY

 

 

 

 

 

 

 

 

STATE

 

 

ZIP

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ACCIDENT

LOSS HISTORY: Have you ever filed a marine claim?

 

 

YES (PLEASE EXPLAIN BELOW)

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LIST ALL MARINE INSURANCE CLAIMS YOU OR YOUR OPERATOR HAVE FILED REGARDLESS OF VESSEL INVOLVED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(INCLUDING BODILY INJURY TO PASSENGERS OR CREW). IF MORE ROOM IS NEEDED PLEASE USE SEPARATE SHEET OF PAPER.

 

 

 

 

 

DATE

DETAILS OF CLAIM

 

AMOUNT PAID

STATUS

 

$

 

OPEN

 

 

CLOSED

 

$

 

OPEN

 

 

CLOSED

 

$

 

OPEN

 

 

CLOSED

CONTINUED ON SECOND PAGE

CLAKES APP_pleasure REV. 05/19

CONTINUED

GENERAL INFORMATION

IS THIS VESSEL USED FOR CHARTER OR ANY OTHER COMMERCIAL PURPOSES?

IF YES, PLEASE EXPLAIN

 

 

 

 

 

YES

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DO YOU TOW SKIERS?

IS VESSEL USED FOR RACING?

 

IS VESSEL USED AS A LIVEABOARD?

PRIMARY RESIDENCE

 

 

YES

NO

YES

NO

 

 

YES

NO

 

SECONDARY RESIDENCE

 

 

HAS ANY NAMED INSURED EVER BEEN

CONVICTED OF A

 

ANY DRIVING

VIOLATIONS IN THE LAST THREE

 

HAVE YOU EVER BEEN REFUSED INSURANCE OR

 

FELONY?

YES (PLEASE EXPLAIN BELOW)

NO

 

YEARS?

YES (PLEASE EXPLAIN BELOW)

NO

CANCELLED?

YES (PLEASE EXPLAIN BELOW)

NO

ANY EXISTING OR PRIOR DAMAGE TO THE YACHT?

YES

NO

CURRENT INSURANCE CARRIER

 

EXPIRATION DATE

CURRENT PREMIUM

 

IF YES, EXPLAIN ON FIRST PAGE UNDER CLAIM INFORMATION

 

 

 

 

 

 

 

$

 

LIST PREVIOUS VESSELS OWNED OR OPERATED:

#

YEAR

LENGTH

MANUFACTURER

OWNED

1. OPERATED

OWNED

2. OPERATED

OWNED

3. OPERATED

OPERATOR / CREW INFORMATION

# YEARS

# YEARS BOATING EXPERIENCE

ARE YOU A LICENSED CAPTAIN?

# YRS LICENSED

 

HAVE YOU COMPLETED A BOATING SAFETY COURSE?

YES

NO

 

 

YES

NO

 

 

IF YES, PLEASE INDICATE:

USPS

USCG

 

USCG AUX

 

 

 

 

 

 

 

 

 

 

 

 

IS VESSEL OWNER OPERATED?

DO YOU EMPLOY A CAPTAIN?

DO YOU EMPLOY

CREW?

HOW MANY?

CAPTAIN & CREW COVERAGE REQUESTED?

YES

NO

YES

NO

YES

NO

 

 

YES

NO

 

 

 

 

 

 

 

 

 

 

 

 

LIST ADDITIONAL OPERATORS BELOW

#

1.

2.

3.

NAME

DATE OF

DRIVERS LICENSE NUMBER & STATE

YRS. OPERATING

USCG

 

BOATING

BIRTH

EXPERIENCE

LICENSE

CLAIMS

 

 

 

 

 

 

 

 

YES

NO

YES

NO

 

 

 

 

YES

NO

YES

NO

 

 

 

 

YES

NO

YES

NO

CORPORATE OWNERSHIP AND CORPORATE OFFICERS

NAME

PERCENTAGE OWNERSHIP

TITLE

DO YOU OPERATE VESSEL

USCG LICENSED

 

 

 

YES

NO

YES

NO

 

 

 

YES

NO

YES

NO

 

 

 

YES

NO

YES

NO

ADDITIONAL INSURED / CERTIFICATE HOLDER / LOSS PAYEE INFORMATION

(PLEASE ATTACH ADDITIONAL SHEET IF MORE SPACE IS NEEDED)

 

NAME

 

ADDRESS: STREET, CITY, STATE, ZIP

 

INTEREST

 

 

 

 

 

 

AI

CERT HOLDER

LOSS PAYEE

 

 

 

 

 

 

 

 

 

 

 

 

AI

CERT HOLDER

LOSS PAYEE

 

 

 

 

 

 

 

 

 

 

 

 

AI

CERT HOLDER

LOSS PAYEE

 

 

 

 

 

 

 

 

 

 

 

SPECIAL CONDITIONS / COMMENTS

 

 

 

 

 

 

(PLEASE USE TO EXPLAIN ANY “YES” RESPONSES WHERE AN EXPLANATION IS REQUESTED)

 

 

 

1.Any person who knowingly and with intent to defraud any insurance company or another person files an application for insurance containing any materially false information, or conceals for the purposes of misleading, information concerning a fact material thereto, commits a fraudulent insurance act, which is a crime and subjects the person to criminal and civil penalties.

2.As part of underwriting procedures, an investigative consumer report may be made which could include information regarding your character, general reputation, personal characteristics and mode of living. This information will be used solely by the underwriting insurance company(s). Future reports may be used for an update, renewal or extension of your insurance. At your request, we will provide you with the sources of these reports, their addresses and customer service phone numbers for verification and correction of your information.

3.By signing this document I declare that the statements within this Watercraft Application are true to the best of my knowledge and belief. The selections indicated within this Watercraft Application accurately reflect the limits, coverages and deductibles I desire. I understand and agree that the company may obtain from third parties information regarding me, my watercraft, and listed operators, including driving records, financial credit information and prior claims information. I understand that I have the right of access and correction with respect to all such information collected and that the company will provide further information regarding my statutory rights upon request.

 

HOW DID YOU HEAR ABOUT US?

EFFECTIVE DATE OF COVERAGE

APPLICANT SIGNATURE

DATED

 

 

 

 

 

 

My (the producer) signature verifies that all of the information on the application has been obtained by me

PRODUCER (AGENT) SIGNATURE

DATED

from the applicant and that I have no reason or basis to believe that the information is anything but truthful.

 

 

 

 

 

 

 

PAGE 2

CLAKES APP_pleasure REV. 05/19

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part 1 to filling out charter spectrum repair insurce

You need to write down the appropriate information in the MANUFACTURER, SERIAL NO, YEAR, EQUIPMENT TRAILER DINGHY DINGHY, YEAR, YEAR, LENGTH, MANUFACTURER, MANUFACTURER, SERIAL NO, SERIAL NO, COVERAGE INFORMATION (Client must, HULL VALUE REQUESTED (inc, LIABILITY LIMIT REQUESTED, and PERSONAL EFFECTS & FISHING EQUIP space.

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Make sure you provide the crucial information within the AMOUNT PAID $ $ $, STATUS OPEN CLOSED OPEN CLOSED, and CONTINUED ON SECOND PAGE CLAKES section.

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The IS THIS VESSEL USED FOR CHARTER OR, IF YES, GENERAL INFORMATION, YES, DO YOU TOW SKIERS, YES, YES (PLEASE EXPLAIN BELOW), HAS ANY NAMED INSURED EVER BEEN, LENGTH, YEAR, IS VESSEL USED FOR RACING, YES, IS VESSEL USED AS A LIVEABOARD, YES, and ANY DRIVING VIOLATIONS IN THE LAST area will be your place to place the rights and obligations of all sides.

charter spectrum repair insurce IS THIS VESSEL USED FOR CHARTER OR, IF YES, GENERAL INFORMATION, YES, DO YOU TOW SKIERS, YES, YES (PLEASE EXPLAIN BELOW), HAS ANY NAMED INSURED EVER BEEN, LENGTH, YEAR, IS VESSEL USED FOR RACING, YES, IS VESSEL USED AS A LIVEABOARD, YES, and ANY DRIVING VIOLATIONS IN THE LAST fields to fill out

Finalize by reviewing the next sections and filling them in as needed: NAME, NAME, CORPORATE OWNERSHIP AND CORPORATE, TITLE, DO YOU OPERATE VESSEL, ADDITIONAL INSURED / CERTIFICATE, (PLEASE ATTACH ADDITIONAL SHEET IF, ADDRESS: STREET, SPECIAL CONDITIONS / COMMENTS, (PLEASE USE TO EXPLAIN ANY “YES”, YES, YES, YES, USCG LICENSED, and YES.

NAME, NAME, CORPORATE OWNERSHIP AND CORPORATE, TITLE, DO YOU OPERATE VESSEL, ADDITIONAL INSURED / CERTIFICATE, (PLEASE ATTACH ADDITIONAL SHEET IF, ADDRESS: STREET, SPECIAL CONDITIONS / COMMENTS, (PLEASE USE TO EXPLAIN ANY “YES”, YES, YES, YES, USCG LICENSED, and YES in charter spectrum repair insurce

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