Charter Lakes Insurance Application PDF Form - FormsPal

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.

Question	Answer
Form Name	Charter Lakes Insurance Application
Form Length	2 pages
Fillable?	Yes
Fillable fields	263
Avg. time to fill out	26 min 35 sec
Other names	charter insurance application, charter spectrum repair insurce, what is a dte insurance form, acord 82 watercraft application

12

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
NAME	BIRTH	DRIVERS LICENSE NUMBER & STATE	EXPERIENCE	LICENSE		CLAIMS
	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

How to Edit Charter Lakes Insurance Application Online for Free

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Step 1: Click the "Get Form Now" button to start out.

Step 2: At the moment you're on the file editing page. You can edit and add text to the document, highlight specified content, cross or check specific words, insert images, insert a signature on it, delete needless areas, or eliminate them entirely.

Complete the boat insurance quote form PDF by providing the information needed for each section.

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.

Finishing charter spectrum repair insurce part 2

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

stage 3 to finishing charter spectrum repair insurce

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 LIVE, ABOARD 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, USC, G 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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