YACHT APPLICATION PROSPECT-SEGUROS STEVEN ROSSY

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Hi there. With this short questioner we will be able to quote your boat insurance. We currently work with Blue Waters Insurance, Corp., Guardian Insurance, Multinational Insurance Company and Optima Seguros. Please submit your questioner with all the information so that your quote can be as accurate as possible. Thanks!
2
TERMS AND CONDITIONS

The statements and answers provided herein are warranted by me to be true and correct. If incorrect answers are provided (either by error, omission, or neglect), I will be in breach of this warranty and the policy, if issued, will be void from inception. I understand I must fill out every question and that no question should remain unanswered. If a question is inapplicable, I am aware that I must write "N/A" to so indicate. I agree that this declaration shall form the basis of the contract of insurance between me and you. I also agree that if the policy is issued, it was issued by you based upon and in reliance of the truthfulness and completeness of the answers provided herein. I further declare and agree that if the statements and particulars above have been completed by any person other than me such person providing the responses shall deemed to be my agent and not your agent.
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Terms and Conditions* This field is required.
4
The vessel is owned by a:* This field is required.
Natural person
Corporation or a legal entity
5
Vessel owner full name* This field is required.
6
Corporate Name, include all beneficial owners
7
Date Of Application* This field is required.
Date
Month
Day
Year
8
Age:* This field is required.
9
Address* This field is required.
Street Address
10
City, State, Zip* This field is required.
11
Employer* This field is required.
12
Occupation* This field is required.
13
Position* This field is required.
14
Years with employer* This field is required.
15
Mobile Number:* This field is required.
16
Phone (Other than mobile)* This field is required.
17
Email* This field is required.
18
Beneficial Owner(s) (If not the Insured):
(This should be completed if vessel is owned by a company or if the beneficial owner of the vessel is someone other than the Named Assured)
19
Details of boating experience Provide in chronological order list of ALL boats owned or operated and their length over all LOA* This field is required.
20
Provide boating/navigation courses completed* This field is required.
Please Select
Please Select
USCG Auxiliaty
USCG Captain
Power Squadrom
Comisionado Navegacion
BOSS
NONE
21
Please confirm USCG Auxiliary* This field is required.
USCG Auxiliary
22
Please confirm USCG Captain* This field is required.
USCG Captain
23
Please Confirm Power Squadron* This field is required.
Power Squadron
24
Please Confirm Comisionado Navegacion* This field is required.
Comisionado Navegacion
25
Please Confirm BOSS* This field is required.
BOSS
26
Navigation License Number
If you don't have the information at this time please continue to next question.
27
Please Upload or take picture of Owner Navigation License. If you don’t have it at the moment please continua to next item.
28
Have you or anyone who will operate your yacht had any accidents or losses (even if no insurance claim was filed) in connection with any vessel you have operated, owned or was under your control?* This field is required.
YES
NO
29
Confirm No Previous Losses* This field is required.
Please Select
Please Select
No previous losses.
30
If yes, please provide full details, including dates and amounts paid* This field is required.
31
Have you or any person you have allowed or may allow to use your yacht, ever been charged with or convicted of any offence involving dishonesty or operating a motor vehicle or vessel under the influence of Alcohol and/or Drugs?* This field is required.
YES
NO
32
Please confirm you have never been convicted of a felony.* This field is required.
Please Select
Please Select
I have never been convicted of a felony.
33
If yes please provide full details* This field is required.
34
Have you ever had Insurance declined, non-renewed or cancelled?* This field is required.
YES
NO
35
If yes, please provide full details* This field is required.
36
Previous Insurer* This field is required.
Please Select
Please Select
Blue Water/Aspen
Cooperativa Seguros Multiples
Guardian
Mapfre
Multinational
Optima
NONE
37
Renewal Date:* This field is required.
Date
Month
Day
Year
38
Please confirm there is no previews insurer by marking N/A.* This field is required.
Please Select
Please Select
N/A
39
Do you Employ a Captain?* This field is required.
Yes
No
40
Please confirm if you employ a paid captain* This field is required.
Please Select
Please Select
A Captain is Employed
41
Please confirm you don't employ a paid captain by marking N/A* This field is required.
Please Select
Please Select
N/A
42
If yes, provide full name and experience:* This field is required.
43
Captains name* This field is required.
44
Captains phone number* This field is required.
Please enter a valid phone number.
45
Captain Age* This field is required.
46
Captains Nav License number
If you don't have the information at this time please continue to next question.
47
Please upload or take picture of Captains Nav License
48
Please upload or take picture of Captains CV
49
Has the Captain had any losses or previous accidents in connection with any vessel under their control?* This field is required.
Yes
No
50
If yes, please provide full details* This field is required.
51
Do you Employ a paid crew?* This field is required.
Yes
No
52
Please confirm if you employ a paid crew* This field is required.
Please Select
Please Select
Yes
No
53
Name Permanent Crew* This field is required.
54
Name Temporary Crew* This field is required.
55
Quantity of Employed crew:* This field is required.
56
Details of any U.S. Nationals* This field is required.
57
Additional Operators?* This field is required.
Yes
No
58
Please confirm there are no additional operators by marking N/A* This field is required.
Please Select
Please Select
N/A
59
Amount of additional operators* This field is required.
Please Select
Please Select
1
2
3
4
5
6
7
60
If yes, provide name, age, relationship and boating experience.* This field is required.
61
Have any of the additional operators had any losses or previous accidents (even if no insurance claim was filed) in connection with any vessel under their control?* This field is required.
Yes
No
62
If yes, please provide full details* This field is required.
63
Please Upload Additional operator 1 Navigation License
64
Please Upload Additional operator 2 Navigation License
65
Please Upload Additional operator 3 Navigation License
66
Please Upload Additional operator 4 Navigation License
67
Please Upload Additional operator 5 Navigation License
68
Please Upload Additional operator 6 Navigation License
69
Please Upload Additional operator 7 Navigation License
70
Name Of Vessel* This field is required.
71
Manufacturer* This field is required.
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Model* This field is required.
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Type* This field is required.
Small Boat
Center Console
Day Cruiser / Walk Around
Yacht
Sali Boat
Pneumatic Boat
Pure Regatta Sailboat
Jet Ski
Monotype Sailboat
74
Passenger Capacity* This field is required.
Please Select
Please Select
N/A
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
75
Year Built* This field is required.
76
Port of Registry* This field is required.
77
Flag / Country of Registry* This field is required.
78
Lenght* This field is required.
79
Beam* This field is required.
80
Draft* This field is required.
81
Hull Identification Number
If you don't have the information at this time please continue to next question.
82
Hull Material* This field is required.
Please Select
Please Select
Aluminum
Ferrocement
Fiberglass
Inflatable Boat with Fiberglass
Inflatable Boat without Fiberglass
Steel
Wood
83
Mast Material* This field is required.
Please Select
Please Select
N/A
Carbon Fiber
Stainless Steel
Aluminium
84
Please Upload or take picture of vessel license. If you don’t have it at the moment please continue to next item.
85
Maximum Design Speed* This field is required.
Please Select
Please Select
5 kn/5.7 mph
6 kn/6.9 mph
7 kn/8.0 mph
8 kn/9.2 mph
9 kn/10.3 mph
10 kn/11.5 mph
11 kn/12.6 mph
12 kn/13.8 mph
13 kn/14.9 mph
14 kn/16.11 mph
15 kn/17.2 mph
16 kn/18.4 mph
17 kn/19.5 mph
18 kn/20.7 mph
19 kn/21.8 mph
20 kn/23.0 mph
21 kn/24.1 mph
22 kn/25.3 mph
23 kn/26.4 mph
24 kn/27.6 mph
25 kn/28.7 mph
26 kn/29.9 mph
27 kn/31.0 mph
28 kn/32.2 mph
29 kn/33.3 mph
30 kn/34.5 mph
31 kn/35.6 mph
32 kn/36.8 mph
33 kn/37.9 mph
34 kn/39.1 mph
35 kn/40.2 mph
36 kn/41.4 mph
37 kn/42.5 mph
38 kn/43.7 mph
39 kn/44.8 mph
40 kn/46.0 mph
41 kn/47.1 mph
42 kn/48.3 mph
43 kn/49.4 mph
44 kn/50.6 mph
45 kn/51.7 mph
46 kn/52.9 mph
47 kn/54.0 mph
48 kn/55.2 mph
49 kn/56.3 mph
50 kn/57.5 mph
51 kn/58.6 mph
52 kn/59.8 mph
53 kn/60.9 mph
54 kn/62.1 mph
55 kn/63.2 mph
56 kn/64.4 mph
57 kn/65.5 mph
58 kn/66.7 mph
59 kn/67.8 mph
60 kn/69.0 mph
61 kn/70.1 mph
62 kn/71.3 mph
63 kn/72.4 mph
64 kn/73.6 mph
65 kn/74.8 mph
66 kn/75.9 mph
67 kn/77.1 mph
68 kn/78.2 mph
69 kn/79.4 mph
70 kn/80.5 mph
MORE THAN 70 kn/80.5 mph
N/A
86
Primary Power* This field is required.
Sail
Inboard
Outboard
Surface Drive or Stern Drive
Inboard/Outboard
Other
87
Type of fuel:* This field is required.
Gasoline
Diesel
Other
88
Has the Vessel been surveyed in the last three years?* This field is required.
Yes
No
89
If yes, please provide surveyor's full name.* This field is required.
90
Vessel last survey* This field is required.
Month
Day
Year
91
If Vessel not surveyed in las three year choose N/A* This field is required.
Please Select
Please Select
N/A
92
Is the vessel currently for sale?* This field is required.
Yes
No
93
Please Confirm the vessel is not for sale* This field is required.
Please Select
Please Select
Vessel is not for sale at this moment.
94
If yes provide sale price* This field is required.
95
What was the purchase price of the boat (exact price paid to seller)?* This field is required.
96
What was the approximate date of purchase?* This field is required.
Date
Month
Day
Year
97
Has the vessel been in any accident or suffered any damage not reported above?* This field is required.
Yes
No
98
If yes please provide full details* This field is required.
99
Built in firefighting system:* This field is required.
Yes
No
100
Date serviced* This field is required.
Date
Month
Day
Year
101
Vessel Pictures
Please Select
Please Select
I would like to take or upload pictures of the vessel at this time.
I would NOT like to take or upload pictures of the vessel at this time.
102
Bow Picture
103
Stern Picture
104
Starboard Picture
105
Port Picture
106
Generator Picture 1
107
Generator Picture 2
108
Generator Picture 3
109
Electronics Picture 1
110
Electronics Picture 2
111
Electronics Picture 3
112
Additional Vessel Pictures
Please Select
Please Select
I would like to take or upload additional pictures at this time.
I would NOT like to take or upload additional pictures of engines at this time.
113
Additional Picture 1
114
Additional Picture 2
115
Additional Picture 3
116
Additional Picture 4
117
Additional Picture 5
118
Additional Picture 6
119
Additional Picture 7
120
Additional Picture 8
121
Additional Picture 9
122
Additional Picture 10
123
Additional Picture 11
124
Additional Picture 12
125
Engines Make and Model* This field is required.
126
Engines Year Built* This field is required.
127
Quantity of engines* This field is required.
Please Select
Please Select
1
2
3
4
5
6
7
8
128
Horsepower each* This field is required.
129
Engine (1) Serial Number
If you don't have the information at this time please continue to next question.
130
Engine (2) Serial Number
If you don't have the information at this time please continue to next question.
131
Engine (3) Serial Number
If you don't have the information at this time please continue to next question.
132
Engine (4) Serial Number
If you don't have the information at this time please continue to next question.
133
Engine (5) Serial Number
If you don't have the information at this time please continue to next question.
134
Engine (6) Serial Number
If you don't have the information at this time please continue to next question.
135
Engine Pictures
Please Select
Please Select
I would like to take or upload pictures at this time.
I would NOT like to take or upload pictures of engines at this time.
136
First Picture of Engines
137
Second Picture of Engines
138
Third Picture of Engines
139
Picture of Engine 1 Serial Number
140
Picture of Engine 2 Serial Number
141
Picture of Engine 3 Serial Number
142
Picture of Engine 4 Serial Number
143
Picture of Engine 5 Serial Number
144
Picture of Engine 6 Serial Number
145
Picture of Engine 7 Serial Number
146
Picture of Engine 8 Serial Number
147
Vessel Primary Location:* This field is required.
Please Select
Please Select
Marina PDR Operations (Puerto del Rey)
VMF Holding (Villa Marina)
Marina Puerto Chico
Sunbay Marina
Palmas del Mar Private Slip
Marine Credit SPS - Palmas del Mar
Club Nautico de Palmas del Mar
Club Nautico de San Juan
San Juan Bay Marina
Congrejo's Yacht Club
Club Deportivo del Oeste
Club Nautico de Boqueron
Marina Boqueron
Marina Pescaderia - Cabo Rojo
Club Nautico de Ponce
Club Nautico de Salinas
El Dorado - Salinas
Full Moon Marina - Salinas
La Barca - Salinas
Clun Nautico de Guayama
Club Nautico de Pozuelo
Other.
148
Please Type the Vessels Location* This field is required.
149
On the primary location the vessel will be:* This field is required.
Afloat
Dry Stack
Trailer
Bed
Other
150
Afloat Slip #* This field is required.
151
Dry Stack Level* This field is required.
152
Dry Stack #* This field is required.
153
Will the vessel be moved for more than 30 consecutive days to another location during the year?* This field is required.
Yes
No
154
Where is the additional location?* This field is required.
Please Select
Please Select
Marina PDR Operations (Puerto del Rey)
VMF Holding (Villa MArina)
Marina Puerto Chico
Sunbay Marina
Palmas del Mar Private Slip
Marine Credit SPS - Palmas del Mar
Club Nautico de Palmas del Mar
Club Nautico de San Juan
San Juan Bay Marina
Congrejo's Yacht Club
Clun Deportivo del Oeste
Club Nautico de Boqueron
Marina Boqueron
Marina Pescaderia - Cabo Rojo
Club Nautico de Ponce
Club Nautico de Salinas
El Dorado - Salinas
Full Moon Marina - Salinas
La Barca - Salinas
Clun Nautico de Guayama
Club Nautico de Pozuelo
Other
155
Please Type Other Additional Vessels Location* This field is required.
156
On the additional location the vessel will be:* This field is required.
Afloat
Dry Stack
Trailer
Bed
Other
157
Afloat Slip # of Additional Location * This field is required.
158
Dry Stack Level of Additional Location* This field is required.
159
Dry Stack # of Additional Location* This field is required.
160
Is the Yacht subject to finance or mortgage?* This field is required.
Yes
No
161
Please confirm marking N/A* This field is required.
Please Select
Please Select
N/A
162
If yes, please provide original amount of loan* This field is required.
163
Name of lender/Loss Payee/Mortgage:* This field is required.
164
Loan Number
If you don't have the information at this time please continue to next question.
165
Address (City, Statue, Zip code)
If you don't have the information at this time please continue to next question.
166
Please provide all previous vessels you have owned. Include Manufacturer, Model and length. If you have not owned a vessel before please wright NONE:* This field is required.
167
Name of the Dealer or Broker who sold you the vessel:* This field is required.
168
Detail of use:* This field is required.
Private and Pleasure only
Sport Fishing Rental
Skipper Charter Use
Bareboat Charter Use
Tourist Rides
Other
169
Will the vessel be used for racing or regattas?* This field is required.
Yes
No
170
Will the vessel be chartered to others?* This field is required.
Please Select
Please Select
Yes
No
171
Will the vessel be loaned to others?* This field is required.
Please Select
Please Select
Yes
No
172
Will the vessel be used for commercial purpose?* This field is required.
Please Select
Please Select
Yes
No
173
Will the vessel be used for water skiing, racing or scuba diving?* This field is required.
Please Select
Please Select
Yes
No
174
Will there be any towed Tender/Vessels?* This field is required.
Yes
No
175
If yes please provide full details* This field is required.
176
Required cruising range:* This field is required.
Coastal Waters of Puerto Rico
Waters of Puerto Rico, US & British Virgin Islands
Waters of Puerto Rico, US & British Virgin Islands and Caribbean Sea(excluding waters of Cuba, Colombia and Haiti)
177
Please Confirm* This field is required.
Please Select
Please Select
Coastal Waters of Puerto Rico
Waters of Puerto Rico, US & British Virgin Islands
Waters of Puerto Rico, US & British Virgin Islands and Caribbean Sea (Excluding waters of Cuba, Colombia and Haiti)
178
Anticipated Special Voyages?* This field is required.
Yes
No
179
If Yes please provide float plan and full details for evaluation* This field is required.
180
Yacht Value-Amount applying for Insurance. Not purchase price.* This field is required.
181
The values of all equipment fix to the vessel (GPS, VHF, RADIO, etc) are included in the total value of the Yacht Value Insured.* This field is required.
I understand
182
Equipment (Total)* This field is required.
LEAVE AT "0". PLEASE CONTINUE TO NEXT QUESTION. IT IS CONTEMPLATED IN YACHT VALUE PROVIDED ABOVE.
183
Equipment Detail N/A* This field is required.
N/A
Please Select
N/A
PLEASE CHOOSE N/A AND CONTINUE. IT IS CONTEMPLATED IN YACHT VALUE PROVIDED ABOVE.
184
Yacht Deductible* This field is required.
3.00% But Windstorm 6.00%
Please Select
3.00% But Windstorm 6.00%
5.00% But Windstorm 10.00%
10.00% But Windstorm 15.00%
185
TOTAL SUM INSURED
186
Watercraft Liability* This field is required.
Please Select
Please Select
$1,000,000
$500,000
$300,000
$100,000
Please choose one option.
187
Please Confirm $100,000* This field is required.
Confirmed
188
Please Confirm $300,000* This field is required.
Confirmed
189
Please Confirm $500,000* This field is required.
Confirmed
190
Please Confirm $1,000,000* This field is required.
Confirmed
191
Watercraft Liability Deductible* This field is required.
$0.00
Please Select
$0.00
This will always be $0.00. Please continue.
192
Uninsured Boaters* This field is required.
$25,000
Please Select
$25,000
Please leave this value. Please continue.
193
Uninsured Boaters Deductible* This field is required.
$0.00
Please Select
$0.00
This will always be $0.00. Please continue.
194
Personal Effects* This field is required.
Please Select
Please Select
$500
$1,000
$5,000
$10,000
195
Please Confirm $500* This field is required.
Confirmed
196
Please Confirm $1,000* This field is required.
Confirmed
197
Please Confirm $5,000* This field is required.
Confirmed
198
Please Confirm $10,000* This field is required.
Confirmed
199
Personal Effects Deductible* This field is required.
$100
Please Select
$100
$150
$250
200
Medical Payments* This field is required.
$5,000
Please Select
$5,000
$10,000
$25,000
201
Please Confirm $5,000* This field is required.
Confirmed
202
Please Confirm $10,000* This field is required.
Confirmed
203
Please Confirm $25,000* This field is required.
Confirmed
204
Medical Payments Deductible* This field is required.
$0
Please Select
$0
$100
$250
205
You need insurance for a tender?* This field is required.
Yes
No
206
If no please confirm by marking Not Applicable
Please Select
Please Select
N/A
207
Tender Fuel* This field is required.
Please Select
Please Select
Gas
Diesel
208
Tender Value* This field is required.
209
Tender Deductible* This field is required.
Please Select
Please Select
3%
210
Tender number of engines* This field is required.
Please Select
Please Select
1
2
3
4
211
Manufacturer and Model* This field is required.
212
Year* This field is required.
213
Hull ID
If you don't have the information at this time please continue to next question.
214
Length* This field is required.
215
Engine make and model* This field is required.
216
Quntity of engines* This field is required.
Please Select
Please Select
1
2
3
4
5
6
7
8
217
HP* This field is required.
218
Engine Serial Number* This field is required.
219
Home Port. Provide Port Marina City* This field is required.
If not applicable Type N/A
220
Tender is:* This field is required.
Afloat/Wet Slip
Dry Stack
Trailer
Bed
Onshore
Other
221
Slip #* This field is required.
If not applicable Type N/A
222
Dry Stack Level* This field is required.
If not applicable Type N/A
223
Dry Stack #
If not applicable Type N/A
224
Need to insure a trailer* This field is required.
Yes
No
225
Please confirm marking Not Applicable* This field is required.
Please Select
Please Select
N/A
226
Trailer Value/Limit* This field is required.
227
Trailer Deductible* This field is required.
Please Select
Please Select
3%
228
Trailer Serial #
If you don't have the information at this time please continue to next question.
229
Manufacturer* This field is required.
230
Year Built* This field is required.
231
Please share exact location where trailer isstored.* This field is required.
232
Please upload or take picture of trailer license.
233
Trailer Pictures
Please Select
Please Select
I would like to take or upload trailer pictures at this time.
I would NOT like to take or upload trailer pictures of engines at this time.
234
Trailer picture 1
235
Trailer Picture 2
236
Trailer Picture 3
237
Trailer License Plate
238
Who is going to be responsible for the vessel before and after the hurricane?* This field is required.
Full Name
239
Phone Number* This field is required.
Please enter a valid phone number.
240
Email* This field is required.
241
What is the name, address and contact details of the marina or residence where the vessel will be kept during a hurricane* This field is required.
242
What planned pre-arrangements have you made or will do for the safety of your vessel if a named storm warning is issued* This field is required.
243
Do You have an Emergency Haul Out Plan with a marina?* This field is required.
Yes
No
244
If “YES” please provide details, name of marina and procedures:* This field is required.
245
How frequently, do you or the person named above visit the vessel if not permanently crewed?* This field is required.
246
If the Insured Vessel is a sailboat will the vessel be hauled and blocked ashore during hurricane season?* This field is required.
If not a sail boat pleaser wright N/A
247
If the Insured Vessel is a sailboat does she have a “hurricane pit” and will it be used throughout hurricane season?* This field is required.
If not a sail boat pleaser wright N/A
248
If the vessel will be ashore are all the stands supporting the vessel chained together?* This field is required.
Please Select
Please Select
Yes
No
N/A
249
Will all canvas and/or cushions and/or outriggers removed?* This field is required.
Please Select
Please Select
Yes
No
N/A
250
If the vessel is to be moved to a hurricane hole what is the travel time by water* This field is required.
251
Do you have any alternative plans if the above plan becomes unlikely Please provide full details* This field is required.
252
Have you ever had to prepare for a storm before?* This field is required.
Yes
No
253
If so, we would appreciate any tips or comments you may have* This field is required.
Should be Empty: