Charter Vessel Program

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Charter Vessel Program Application for SIX Passenger Charter Vessels

Insured Information

Name of Insured (as will read on the policy):*

Owner's Name:*

Effective Date:*

MM slash DD slash YYYY

Corporate Name (If any):

Is Corporation for sole purpose of ownership of vessel?

Yes

If no; explain:

Address, City, State:*

Phone: Home:

Bus:

Email*

Present Insurer:

Expiration Date:*

MM slash DD slash YYYY

Prior Vessels Owned or Operated:

Year

Type

Length

How Long Owned

Year

Type

Length

How Long Owned

Year

Type

Length

How Long Owned

Losses in past 5 years? (on any vessel):

Yes

If yes, please list date, type, amount and status.

Claims:

Vessel Information

Vessel Name:*

Year:*

Make:*

Model:*

Length:

Construction:

Steel

Fiberglass

Wood

Aluminium

Other:

Hull ID/Serial #:

Has vessel been Coast Guard Inspected:

Yes

Doc. #:

Is vessel more than 6 passenger:

Yes

Date of Vessel's Last Survey:

Surveyed by whom:

Purchase Date: (MM/DD/YY)*

MM slash DD slash YYYY

Purchase Price:*

Loss Payee:

Address:*

ENGINE INFORMATION

Year:*

H.P Per Engine:*

Max Speed:*

NUMBER:*

Single

Twin

Triple

Quad

TYPE:

Gas

Diesel

Manufacturer:

Is vessel equipped with the following:

high water:

Yes

High Water Level Alarm (Outboard only)

Fume Detectors

Yes

Fume Detectors

Automatic Fire Extinguishing System

Yes

Automatic Fire Extinguishing System with Manual Override

NAVIGATION DETAILS

Maximum # passengers any one trip:

Address:

Marina

Private Residence

Other

Storage Address

Type of Charters:

Any overnight charters?

Yes

Please provide your website address, if applicable:

Do passengers swim, snorkel, scuba dive or water ski for the insured vessel:

Yes

If yes, explain:

Average Number of Charters per Year:

Lay up period

Yes

To:

land-water

On Land

In Water

If lay up period, give location:

Is this vessel being held for sale?

Yes

CAPTAIN INFORMATION

Is vessel Captain owned?

Yes

Total Number of Crew:

Captain Name:*

D.O.B:*

MM slash DD slash YYYY

Years with Insured:*

Prior Experience:*

Does Captain have a current USCG “Operator of Uninspected Passenger Vessel License”?

Yes

Other Licenses and Certifications:

Name of each crew member, job each performs and years with Insured:

NAME

JOB DESCRIPTION

YEARS WITH INSURED

Name

JOB DESCRIPTION

YEARS WITH INSURED

Name

JOB DESCRIPTION

YEARS WITH INSURED

Name

JOB DESCRIPTION

YEARS WITH INSURED

Name

JOB DESCRIPTION

YEARS WITH INSURED

Name

JOB DESCRIPTION

YEARS WITH INSURED

COVERAGES

Hull

Hull LIMIT

Trailers

Trailers LIMIT

Personal Effects

Personal Effects LIMIT

P&I

P&I LIMIT

Towing

Towing LIMIT

U/B

U/B LIMIT

Fuel Spill Liability

Fuel Spill Liability LIMIT

Med Pay

Med Pay LIMIT

You understand and agree this application is a request for a quote based on the information provided herein. You understand and agree the actual coverage, terms and conditions offered by MPG may be different than your request contained herein. The actual terms and conditions for coverage provided are represented by the policies issued and supersede any request or representations made prior to issuance.

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime.

The applicant represents that the above statements and facts are true and that no material facts have been suppressed or misstated.

Print Name:*

Title: