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Watercraft - PERSONAL LINES PACKAGE APPLICATION
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Short Description: WATERCRAFT COVERAGES/LIMITS OF LIABILITY. WATERCRAFT BOAT INFORMATION. WATERCRAFT ENGINE/OUTBOARD MOTOR. WATERCRAFT TRAILER INFORMATION ...
Content Inside: ACORD
PRODUCER
PERSONAL LINES PACKAGE APPLICATION
WATERCRAFT/INLAND MARINE SUPPLEMENT
APPLICANT'S NAME
DATE
TM
COMPANY CODE: SUB CODE:
WATERCRAFT COVERAGES/LIMITS OF LIABILITY
BOAT # 1 2 OTHER COVERAGES, ENDORSEMENTS AND CREDITS TO APPLY TO BOAT HULL COVERAGE OUTBOARD MOTOR PORTABLE ACCESSORIES TRAILER LIABILITY MEDICAL PAYMENTS DEDUCTIBLES PREMIUM TOTAL PREMIUM
WATERCRAFT BOAT INFORMATION
BOAT # 1 2 BOAT # 1 2 MAX SPEED DATE PURCHASED COST NEW PRESENT VALUE NAME OF BOAT WATERS NAVIGATED TERR BERTH/STORAGE LOCATION LAY UP PERIOD POWER IB OB WTR IO SAIL JET HULL TYPE HULL MATERIAL FUEL TANK REGISTRATION NUMBER HULL ID # YEAR MAKE/MODEL WEIGHT LENGTH
DRY DRY
AFLOAT AFLOAT
WATERCRAFT ENGINE/OUTBOARD MOTOR
BOAT YEAR # 1 2 MAKE/MODEL SERIAL NUMBER HORSE POWER DATE PURCH COST NEW PRESENT VALUE OTHER
GAS GAS
DIESEL DIESEL
WATERCRAFT TRAILER INFORMATION
BOAT YEAR # 1 2 MANUFACTURER/MODEL SERIAL # # AXLES CAPACITY
WATERCRAFT EQUIPMENT INFORMATION
BOAT # 1 2 BILGE PUMP COOK STOVE CO2-CHEMICAL SYS FIRE EXT DEPTH SOUNDER SHIP TO SHORE RADIO OTHER
HULL INFORMATION
EXPLAIN ALL "YES" RESPONSES IN REMARKS YES NO EXPLAIN ALL "YES" RESPONSES IN REMARKS YES NO
1. IS THE BOAT CHARTERED TO OTHERS? 2. IS THE BOAT USED COMMERCIALLY OR FOR BUSINESS PURPOSES? 3. IS THE BOAT USED FOR RACING? 4. IS THE BOAT USED FOR WATERSKIING?
5. DOES THE APPLICANT EMPLOY A PAID CREW? 6. ANY SLEEPING FACILITIES? (Provide number of beds) 7. ANY EXISTING DAMAGE TO THE BOAT?
GENERAL INFORMATION
EXPLAIN ALL "YES" RESPONSES IN REMARKS YES NO EXPLAIN ALL "YES" RESPONSES IN REMARKS YES NO
1. HAS THE APPLICANT LIVED AT THE CURRENT ADDRESS FOR LESS THAN THREE YEARS? (List previous address) 2. ANY OPERATOR HAVE PHYSICAL/MENTAL IMPAIRMENT? (Not applicable in WI) 3. ANY DRIVERS LICENSE SUSPENDED/REVOKED DURING THE LAST 3 YEARS? 4. ANY OPERATOR HAD AN ACCIDENT/CONVICTION DURING THE LAST 3 YEARS? 5. ANY OTHER INSURANCE WITH THIS COMPANY? (List policy number)
6. ANY LOSSES OCCUR DURING THE LAST 3 YEARS? 7. ANY COVERAGE DECLINED, CANCELLED OR NON-RENEWED DURING THE LAST 5 YEARS? (Not applicable in MO) 8. DURING THE PAST FIVE YEARS, (TEN IN RHODE ISLAND), HAS ANY APPLICANT BEEN CONVICTED OF ANY DEGREE OF THE CRIME OF ARSON? (In RI, failure to disclose the existence of an arson conviction is a misdemeanor punishable by a sentence of up to one year of imprisonment.)
REMARKS
ACORD 87 (2000/12)
PLEASE COMPLETE REVERSE SIDE
© ACORD CORPORATION 1996
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