YACHT & PLEASURE CRAFT INSURANCE PROPOSAL FORM

Unless all material facts are disclosed, this insurance could be invalidated. Material Facts are those facts an Insurer would regard as likely to influence the acceptance and/or assessment of the Proposal. If you are in any doubt about whether facts are material, you should disclose them. A copy of the completed Proposal Form will be supplied on request but you should keep a record (including copies of letters) of all information supplied to us for the purposes of entering into this contract. A specimen Policy is available on request.

DATE INSURANCE IS TO BEGIN

(which cannot be before the proposal is accepted by the Insurers)

EXPIRY DATE

Name of Proposer:

NIB#:

E-mail:

Postal Address:

Telephone:

Office:

Mobile:

Fax:

Occupation:

Age:

Currency (B$ or US$):

GENERAL QUESTIONS

Have you or any member of your family residing with you, or directors where the Proposer is a limited company, ever been convicted of any offence other than driving offences?

YES

Have you or any person in 1. above suffered from diabetes, epilepsy, heart condition, defective vision or hearing, or any other physical or mental disability, infirmity or disease, or had any condition controlled by drugs?

YES

If 'YES' to either of the above, give details:

HULL DETAILS

3. Name of Vessel

Type / Class

Material of Hull

Manufacturer's Name

Year Built

Serial Number

Overall Length

Beam

Maximum Designed Speed with present engine(s)

Has the vessel been surveyed by a qualified surveyor within the past 12 months? (If 'YES', attach a copy of the report.)

YES

Has the vessel been subject to conversion, modification, or amateur construction?

YES

If 'YES', give details:

Details of any security devices or fire extinguishing systems:

Name and address of any Bank or other institution with an interest in the vessel:

MAIN ENGINE DETAILS

Engine

Year

Make

Model

Engine

Horsepower

Fuel used

Inboard / Outboard

Serial Number

AUXILIARY OUTBOARD ENGINES

Are there any auxiliary outboard engines?

YES

If 'YES', give details:

DINGHY / TENDER TO PARENT VESSEL

10.

Is there a tender or dinghy?

YES

If 'YES', give details:

TRAILER

11. Is there a trailer?

YES

If 'YES', give details:

12.

How is the Trailer immobilized when left unattended?

BOAT HANDLING EXPERIENCE

13.

Number of years as owner, crew member, or operator of this type of vessel:

14.

Do you have any special qualifications (e.g. Yacht Masters Certificate)?

YES

15.

Have you had any accidents, incidents, losses or insurance claims during the past five years in connection with any vessel you have sailed or owned?

YES

16.

Have you previously insured any vessel?

YES

17.

Have you ever had an insurance on a vessel cancelled, refused renewal, or renewed only at increased terms?

YES

If 'YES', give details:

MOORINGS

25.

Where is the vessel moored when in commission? If not a Marina, give details of type of mooring and precise location.

26.

Where is the vessel stored when laid up and out of commission?

27.

Dates the vessel is normally laid up and out of commission:

From:

To:

Each year

SUMS INSURED

Value to be Insured

Date Purchased

Purchase Price

28.

Hull and Equipment including any inboard engine

29.

Outboard Motors to Parent Vessel

30.

Dinghy/Tender to Parent Vessel
Must be permanently marked with name of parent vessel

31.

Outboard Motors to Dinghy/Tender

32.

Trailer

33.

Personal effects (if more than $500)

34.

Special equipment Items to be listed with individual values on a separate sheet

LIABILITY, PROTECTION AND INDEMNITY

35.

Is this insurance required?

YES

36.

Do you want this Section of the Policy to extend to cover water-skiing, aquaplaning or similar activities?

YES

DEDUCTIBLE

37.

A minimum compulsory deductible of 2% of the Hull & Engines Sum Insured is normally applied (subject to a minimum of $500). Discounts may be available if this amount is increased to 3%, 4%, 5% or 6%. Do you wish to increase the deductible?

YES

NOTICE IN ACCORDANCE WITH THE DATA PROTECTION ACT 2003

The information supplied when arranging this insurance policy may be shared for insurance purposes and services with other companies and organisations. For full details please refer to the Data Protection Act Statement available from Insurance Management (Bahamas) Ltd.

DECLARATION

I/We declare that the above statements made by me/us or written in answer to the questions on this form on my/our behalf by someone else are to the best of my/our knowledge and belief true and complete, and no material fact has been misrepresented, misstated or withheld.

I/We agree that an electronically transmitted signature affixed to this document shall have the force and effect of an original signature.

Signing this form does not bind the proposer to complete the insurance but it is agreed that this form shall be the basis of the contract should a policy be issued. No liability attaches to the Insurers until this proposal has been accepted.

YACHT & PLEASURE CRAFT INSURANCE PROPOSAL FORM

GENERAL QUESTIONS

HULL DETAILS

MAIN ENGINE DETAILS

AUXILIARY OUTBOARD ENGINES

DINGHY / TENDER TO PARENT VESSEL

TRAILER

BOAT HANDLING EXPERIENCE

USE OF VESSEL

MOORINGS

SUMS INSURED

LIABILITY, PROTECTION AND INDEMNITY

DEDUCTIBLE

NOTICE IN ACCORDANCE WITH THE DATA PROTECTION ACT 2003

DECLARATION

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