Fillable BOAT BUILDERS COMPREHENSIVE COVERAGE APPLICATION (Risk Placement Services, Inc.)

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BOAT BUILDERS COMPREHENSIVE COVERAGE APPLICATION (Risk Placement Services, Inc.)

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BOAT BUILDERS COMPREHENSIVE COVERAGE
APPLICATION
APPLICANT
INFORMATION
Nam
e:
Address:
City: State: Zip:
Business Address
(if different from above):
City: State: Zip:
Inspection
Contact:
Inspection
Phone:
Years
in
business
under
present
ownership:
Proposed
effective
Dates
of coverage
From: To:
Loss
Payee(s):
Additional
coverages applied
for under
separate ACORD
application:
Also include
ACORD
125
Property
General
Liability
Crime
Commercial
Auto
GENERAL
INFORMATION
D&O/EPLI
Pollution
Umbrella/Bumbershoot
Liquor
Location(s)
of boat builder:
A.
B.
Construction
of building
where
boat
building
takes
place:
Frame
Other
Steel
Describe:
Masonry
Non-Combustible
Construction
of building
where
boat building
takes
place:
Is
the building
sprinklered?
Yes
No
Protection: Lights Chains
Fully Fenced
Watchman Service
Breakwater
Certified
Central
Station
Alarm
Alarm System
(not Certified)
Other
De
scribe:
Describe Hurricane Emergency
Plan:
Is there a regular snow removal plan
in
effect
for
roofs and access
ways?
Yes
No
Is there a storage facility for
paints, solvents, resins and
other
flammable materials?
Yes
No
If
YES,
describe:
Type
of
vessel(s)
to be
constructed
(if
more
than
one,
list
size and
type -
include
boat
spec.
sheet).
Distance
from coast:
Ave. number
of
vessels
built annually:
Max.value any one
vessel: $
LIMITS OF LIABILITY
Any one
vessel: $
Any one
occurrence: $
Temporary storage
location: $
Wind
deductible: $
Transit
by
land
or water: $ Deductible:
(Min.
$1,000) $
TRANSIT COVERAGE
Is transit by
water
required? No
Yes
If
YES,
for
Boat
Show Delivery Other
Describe:
Is
over-land transit
required? No
Yes
If
YES,
do
you
use
Your
own vehicle
Common
Carrier
Are customers boats used (taken back
into
possession)
for boat
shows?
Yes
No
If
YES,
how
many
annually?
REPAIR COVERAGE
Number
of
vessels typically repaired
annually:
Total value
of
vessel under repair (any one
time) $
Gross repair receipts last
two years: $
20
$
20
LOSS
INFORMATION
Describe any claims
or
losses
with the
past five
years
including the amount paid:
What action has been taken
to
prevent
future occurrences?
Present Insurance
Carrier:
Have you ever had policy coverage declined, cancelled
or
non-renewed?
Yes
No
If
YES,
explain:
PLEASE ATTACH SITE
DIAGRAM
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 RPS
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.
Applicant's Signature:
Date:
Print Name:
Title:
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BOAT BUILDERS COMPREHENSIVE COVERAGE APPLICATION (Risk Placement Services, Inc.)

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Completed 30 July 2020

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