NCBoatInsurance.com: North Carolina Boat Insurance


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User Information

Operational Information

Vessel Information

Applicant Details

Requested Effective Date

First Name*

Middle Name

Last Name *

Address *

City *

Zip Code

Home Phone *

Work Phone *

Email Address *

Where to call? *

Work Home

Lien Holder

Name

Address

City

Zip Code

User Information

Operational Information

Vessel Information

Premium Finance Company

Name	:
Address	:

How are watercraft used by this operation	:
How many years has a boat been used?	:
Experience	:

Organization	:
Operating Period	:
From	:
To	:
Operating From	:

Additional Information

How many years has applicant owned/operated this business?	:
How many years has applicant operated from this location	:
Gross Receipts for Last Year	:
Projected Receipt for this Year	:

Insurance Information

Name of Previous Insurance Carrier	:
Expiration Date	:
Has Applicant been cancelled/non-renewed	:
If yes,explain	:

Navigation Limits Desired & Range of Navigation

Limits	:
Offshore Navigation Limit Desired	:
Location is Applicants(inseason)	:
Vessel is kept on/in a	:
Or in a	:
Address where boat is laid-up Off Season	:
Laid-up Between	:	To
Location is Applicants	:
Vessel is kept Ashore on	:	In A
Vessel is not Ashore during Layup- the vessel is in a	:


List and describe all violations and accidents in past 5years
Incident 1	:
Injury/Death	:	Yes No
Property Damage Amount	:
Incident 2	:
Injury/Death	:	Yes No
Property Damage Amount	:

Operator Information

Name	:
Sex	:	Male Female
Marital Status	:
Birth Date	:
Position	:
USCG Licence	:
Any accidents/violations in past 3years	:	YesNo
If Yes	:
Does the owner employe a Captain/Crew ?	:	YesNo
Does the operator holds the appropriate licence?	:	YesNo

Property Description

Name	:
Length	:
Weight	:
Total Hp	:
Max Speed	:
Fuel	:
Fuel Capacity	:

User Information

Operational Information

Vessel Information

Vessel

Year	:
Manufacturer	:
Model Name	:
Hull ID	:
Purchase Date	:
Purchase Price($)	:
Current Value	:


Engine # 1

Year	:
Manufacturer	:
Model Name	:
Hull ID/Serial Number	:
Purchase Date	:
Purchase Price($)	:
Current Value	:


Engine # 2

Year	:
Manufacturer	:
Model Name	:
Hull ID/Serial Number	:
Purchase Date	:
Purchase Price($)	:
Purchase Value	:


Tender

Year	:
Manufacturer	:
Model Name	:
Hull ID/Serial Number	:
Purchase Date	:
Purchase Price($)	:
Purchase Value	:


Tender Engine

Year	:
Manufacturer	:
Model Name	:
Hull ID/Serial Number	:
Purchase Date	:
Purchase Price($)	:
Purchase Value	:


Trailor

Year	:
Manufacturer	:
Model Name	:
Hull ID/Serial Number	:
Purchase Date	:
Purchase Price($)	:
Purchase Value	:


Boat Type

Aux-Sailboat	Express Cruiser
Houseboat	Motor Yacht
Performance Cruiser	Runabout/Sportboat
Sport Fisherman	Trawler
Other

Boat Power Type

Inboard	Outboard
Inboard/Outboard	Jet Drive
Sail	Runabout/Sportboat
Manual	Other

Hull Material

Fiberglass	Wood
Steel	Aluminium
Advanced Composite	Inflantable
Other

Hull Type

V-Hull	Deep V
Bi Hull	Tri Hull
Tunnel	Displacement
Other
Have the vessels been modified?	Yes No

Safety/AntiTheft Equipment

Equipment	:
Additional Safety/Security Equipment	:
Are Maintenance and Operation Logs kept for this Vessel	:	YesNo
Date of Last Haul and Work Completed	:
Has the vessel or the part of vessel modified?	:	YesNo
Any pre-existing Damage to the vessel	:	YesNo
Days per Year this vessel is used commercially	:
Days per Year this vessel is used for Pleasure	:
Maximun Number of passenger for Hire	:
Average Number of Passenger for Hire	:
Do Passengers stay Onboard the Vessel Overnight	:	Yes No
Is Food or Liquor served to the passenger	:	Yes No
Do passenger Swim,Snorkal or SCUBA from the vessel	:	Yes No
Do you tow passengers on water skiis or water Toys?	:	Yes No

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