Form Yap052008 – Fill Out and Use This PDF

Page 1 of 5

OSPREY YACHT APPLICATION

www.osprey-uwr.co.uk

INSUREDS NAME:

FULL MAILING ADDRESS (including ZIP/Post Code where available):

BENEFICIAL OWNER (this should be completed if vessel is insured in a company name or if the beneficial owner of the vessel is someone other than the Named Insured):

EFFECTIVE DATE FROM: ( MM/DD/YR)

TO:

(MM/DD/YR)

0.01hrs LST

COVERAGES WILL NOT BE PROVIDED UNLESS REQUESTED HEREUNDER

COVERAGES

LIMIT

HULL PHYSICAL DAMAGE

TENDER/DINGHY

MEDICAL PAYMENTS

PERSONAL PROPERTY

TRAILER

BREACH OF WARRANTY (APPLICABLE LOSS PAYEE MUST BE DETAILED ON PAGE 4)

THIRD PARTY LIABILITY

LIABILITY TO PAID CREW

COMMERCIAL PASSENGER LIABILITY

UNINSURED BOATERS (MAXIMUM AVAILABLE US$100,000)

OTHER (PLEASE SPECIFY)

PLEASE TICK THE APPROPRIATE BOXES – IF YOU ANSWER ‘OTHER’ TO ANY SECTION, PLEASE GIVE DETAILS

PRIMARY POWER	SAIL		TYPE OF	SAILBOAT
	OUTBOARD		VESSEL	MOTOR YACHT
	INBOARD			SPORTSFISHER
	OTHER			PERFORMANCE
HULL MATERIAL	FIBREGLASS			HOUSEBOAT
	STEEL			OTHER
	ALUMINIUM		TYPE OF	MONOHULL
	WOOD		HULL	CATAMARAN
	KEVLAR			OTHER
	CARBONFIBRE		FUEL TANK	METAL
	OTHER			FIBREGLASS

PLEASE DETAIL ALL FIRE PREVENTION/EXTINGUISHING EQUIPMENT INSTALLED OR KEPT ON VESSEL:

YES NO

YAP052008

Page 2 of 5	OSPREY YACHT APPLICATION		www.osprey-uwr.co.uk
	ENGINE/OUTBOARD DETAILS
HP	MANUFACTURER	FUEL	YEAR	SERIAL NO#

#1

#2

#3

#2

#3

PRIMARY MOORING LOCATION OF VESSEL (INCLUDING ZIP/POST CODE WHERE AVAILABLE) BETWEEN JULY 1ST – NOV 1ST

PLEASE SPECIFY WHETHER VESSEL WILL BE ASHORE/AFLOAT (MOORED)/OR ON A HOIST. IF YOU ARE UNABLE TO PROVIDE A ZIP/POST CODE, PLEASE ADVISE LONGITUDE & LATITUDE.

WHAT ANTI-THEFT PRECAUTIONS ARE THERE WHEN THE VESSEL IS ON A TRAILER OR KEPT ONSHORE?

ALL WATERS TO BE NAVIGATED THIS POLICY PERIOD (YOU MAY ATTACH AN ITINERARY)

WILL THE VESSEL BE LAID UP DURING THIS POLICY PERIOD (PLEASE DETAIL EXACT DATES & WHETHER ASHORE OR AFLOAT)

TENDERS OR DINGHIES (FULL DETAILS PLEASE):

TRAILER INFORMATION:

YAP052008

Page 3 of 5

OSPREY YACHT APPLICATION

www.osprey-uwr.co.uk

MANUFACTURER

YEAR

DATE PURCHASED

PURCHASE

PRESENT

SERIAL #

BUILT

PRICE

VALUE

GENERAL INFORMATION – IF YOU ANSWER ‘YES’ TO ANY OF THE QUESTIONS BELOW PLEASE GIVE FULL DETAILS ON A SEPARATE SHEET

– ALSO SEE GUIDANCE NOTES.

#

YES

NO

#

YES

NO

1

IS THIS VESSEL CHARTEREDTO

6

IS THIS VESSEL USED FOR WATERSKIING OR

OTHERS WITH A CAPTAIN?

DIVING WHETHER OR NOT VESSEL IS

OPERATED COMMERCIALLY

2

IS THIS VESSEL CHARTERED TO

7

WILL THIS VESSEL BE OPERATED SINGLE

OTHERS WITHOUT A CAPTAIN

HANDED AT NIGHT?

(BAREBOAT)?

3

IS THIS VESSEL USED FOR FARE

8

DOES ANYONE RESIDE ABOARD THE VESSEL?

PAYING PASSENGERS? IF YES

WHAT NUMBER OF PASSENGERS PER

MAX

AVGE

9

WILL THIS VESSEL BE USED FOR RACING

TRIP (MAXIMUM & AVERAGE)

DURING THIS POLICY PERIOD?

NUMBER OF TRIPS PER YEAR

10

WAS ANY INSURANCE DECLINED, CANCELLED

(MAXIMUM & AVERAGE)

OR NON-RENEWED IN THE LAST 5 YEARS?

4

DOES THE APPLICANT EMPLOY PAID

11

HAVE YOU OR ANY NAMED OPERATOR BEEN

CREW? IF YES

INVOLVED IN A LOSS IN THE LAST 10 YEARS

(INSURED OR NOT)?

HOW MANY?

12

HAVE YOU OR ANY NAMED OPERATOR BEEN

CONVICTED OF A CRIMINAL OFFENCE OR

5

IS THIS VESSEL USED

YES

NO

PLEADED NO CONTEST TO A CRIMINAL

COMMERCIALLY OR FOR BUSINESS

ACTION?

PURPOSES?

GUIDANCE NOTES:

1

IS THIS VESSEL CHARTEREDTO OTHERS WITH A CAPTAIN?

Please complete supplementary sheet CAPTAIN CHARTER

2

IS THIS VESSEL CHARTERED TO OTHERS WITHOUT A

Please complete supplementary sheet BAREBOAT CHARTER

CAPTAIN (BAREBOAT)?

4

DOES THE APPLICANT EMPLOY PAID CREW?

Please complete supplementary sheet CREW

9

WILL THIS VESSEL BE USED FOR RACING DURING THIS

Please complete supplementary sheet RACING

POLICY PERIOD?

ALL OPERATORS MUST BE DETAILED – IF THERE ARE MORE THAN TWO OPERATORS PLEASE REQUEST ADDITIONAL OPERATOR SHEETS

A

Full Name

Date of Birth

State of Residence

Violations/Suspensions (including Auto) in last 5 years

1

Yrs of Boat Ownership

Yrs of Boating Experience

Boating Qualifications

Details of Previous vessels Owned/Operated

Have you been involved in a Loss in the last 10 years (insured or not)? If YES please give details & amounts paid:

Have you ever been convicted of a criminal offence or pleaded no contest?

2

Full Name

Date of Birth

State of Residence

Violations/Suspensions (including Auto) in last 5 years

Yrs of Boat Ownership

Yrs of Boating Experience

Boating Qualifications

Details of Previous vessels Owned/Operated

Have you been involved in a Loss in the last 10 years (insured or not)? If YES please give details & amounts paid:

YAP052008

	Page 4 of 5	OSPREY YACHT APPLICATION	www.osprey-uwr.co.uk
		Have you ever been convicted of a criminal offence or pleaded no contest?

WARNING: THIS IS A NAMED OPERATOR ONLY POLICY. ANY PERSON OPERATING THIS VESSEL WITHOUT PROVIDING FULL DETAILS & RECEIVING WRITTEN ACCEPTANCE BY UNDERWRITERS WILL NOT BE COVERED.

LOSS PAYEE(S) (PLEASE PROVIDE NAME & FULL MAILING ADDRESS):

ADDITIONAL ASSUREDS REQUIRED - PLEASE PROVIDE FULL NAME, ADDRESS AND REASON FOR INCLUSION AS AN ADDITIONAL ASSURED.

PLEASE READ BEFORE SIGNING APPLICATION

1.This application will be incorporated in its entirety into any relevant policy of insurance where insurers have relied upon the information contained therein.

2.Any misrepresentation in this application for insurance will render insurance coverage null and void from inception. Please therefore check to make sure that all questions have been fully answered and that all facts material to your insurance have been disclosed, if necessary by a supplement to the application.

3.A photograph of the vessel is required to be submitted with this application.

4.Fraud Statement – please see page 5 of this application form & initial the paragraph relevant to you to indicate that you have read and understood this.

PRODUCING BROKER:

YAP052008

Page 5 of 5

OSPREY YACHT APPLICATION

www.osprey-uwr.co.uk

Applicable in California

For your protection, California law requires the following to appear on this form:

Any person who knowingly presents false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

California Insurance Frauds Prevention Act 1871.2

Applicable in Florida and Idaho

Any person who Knowingly and with the intent to injure, Defraud, or Deceive any Insurance Company Files a Statement of Claim Containing any False, Incomplete or Misleading Information is Guilty of a Felony*

*In Florida – Third Degree Felony

Applicable in Indiana

A person who knowingly and with intent to defraud an insurer files a statement of claim containing false, incomplete, or misleading information commits a felony.

Applicable in Nevada

Pursuant to NRS 686A.291, any person who knowingly and wilfully files a statement of claim that contains any false, incomplete, or misleading information concerning a material fact is guilty of a felony.

Applicable in New Hampshire

Any person who, with purpose to injure, defraud or deceive any insurance company, files a statement of claim containing any false, incomplete or misleading information is subject to prosecution and punishment for insurance fraud, as provided by RSA 638:20.

Applicable in New Jersey

Any person who knowingly and with the intent to defraud any insurance company or other persons, files a statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact, material thereto, commits a fraudulent insurance act, which is a crime, subject to the criminal prosecution and civil penalties

Applicable in New York

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact, material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

Applicable in Ohio

Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

Applicable in Oklahoma

WARNING: Any person who knowingly and with the intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony

Applicable in Pennsylvania

Any person who knowingly and with intent to injure or defraud any insurer files an application or claim containing false, incomplete or misleading information shall, upon conviction, be subject to imprisonment for up to seven years and payment of a fine of up to $15,000.

YAP052008