Marine Insurance Proposal Form

Forenames

Surname

Address

Zip/Postcode

Email Address

Tel (home)

Tel (Work)

Tel (Mobile)

Occupation: (Director is not sufficient)

Date of Birth

Boating Experience (years)

In which craft?

Relevant Qualifications

Particulars of Vessel

Name

Type or class

Hull serial Number (See note 1)

Builder's name

Country of Registration / Flag:

Year Built

Is vessel a conversion?

Yes No

If YES was it converted by professional or amateur. Give full details of conversion and by whom, with date:-

Length

Beam

Draft

Sail Area

Hull Material

Date of last survey

Surveyor's Name

Date boat purchased

Price paid (include currency)

Particulars of Engine(s)

Theft cover for outboards will not apply without a serial number.

Are outboards permanently locked to transom or stored in locked premises when not in use?

Yes No

Maximum designed speed of vessel - specify calibration

If over 17 knots, please note the contents of the Speed Boat Clauses.

Are the following areas fitted with an automatic or remote fire extinguishing system?

Engine room(s)

Yes No

Tank Space

Yes No

Galley

Yes No

State number and make of fire extinguishers carried:

Hand

Remote

Automatic

Gas System

If liquefied petroleum gas (LPG) is used, is the:-

Cylinder kept in self draining cockpit locker

Yes No

Delivery tubing copper or European standard armoured type

Yes No

Cruising Range

Please give full details of the cruising range undertaken or required *

Do you intend to sail single handed?

Yes No

Will the craft be used for : (please state yes or no for each)

Private and pleasure only

Yes No

Houseboat

Yes No

Hire

Yes No

Charter

Yes No

Netting/Potting

Yes No

Demonstration

Yes No

Racing

Yes No

Water Skiing

Yes No

Night Navigation

Yes No

Details of Moorings

Moored at

Type of Mooring

Period vessel in commission:

Period vessel laid up

Laid up at

Ashore Afloat

Sums to be Insured

Hull/Machinery/Gear/Equipment only (See Note 4) *

Tender/Dinghy/Liferaft

Outboard Motor

Trailer

Personal Effects (Maximum £100 any item unless specified)

Navigation Equipment (Maximum £100 any item unless specified)

Mast/Spars/Sails/Standing and Running Rigging (If racing risk required)

Other

Specify currency

Total Sums Insured

Third Party Liability level
Currency is assumed to be as above - Maximum liability within the EU is £2m Sterling or Euro equivalent. Outside EU third party cover can be quoted on request.

When do you require cover to commence

My present policy is with

Current No Claims Bonus entitlement (evidence required)

years

How did you find us?

Please Specify

Declaration

Insurance on any vessel declined or Special Terms imposed

Yes No

Any accident or losses in respect of any vessel

Yes No

Ever been charged with or convicted of any offence involving dishonesty

Yes No

Are you the sole owner of the vessel

Yes No

Is the vessel the subject of any mortgage or financial agreement

Yes No

I declare that to the best of my knowledge and belief, the information given to you on this form is true in every respect. I also declare that if anything on this form was entered by another person, he/she acted as my agent for this purpose. I agree that this proposal and declaration shall be the basis of the Contract between me and the Company.

Note: Submitting this form does not bind the proposer to complete this insurance.

The Company reserves the right to decline any proposal.

The Proposer should keep a record of all information supplied to the Insurer for the purpose of entering into the Contract, and a copy of this Proposal will be supplied on request, within a period of three months after completion.

Edward William Marine Services SL is a Spanish Registered Insurance Agent and as such is not authorised or Regulated by the UK Financial Services Association and is not covered for compensation under the UK Financial Services Compensation Scheme (FSCS)