Have All Surveyor’s Recommendations Been Completed: Yes No If no, explain:
Experien
Valid Coast Guard License: Yes No
Any Marine Claims in the Past 3 Years? Yes No If yes, explain:
Has Insurance Ever Been Canceled or Non-Renewed: Yes No If yes, explain:
Present Insurance Carrier:
EQUIPMENT:
Marine Electronics: Depth Finder SAT Telephone Radar SSB EPIRB
Fire Extinguishers: No. and Type of Extinguishers:
Date Weighed & Tagged: Alarm at Helm: Yes No
Automatic CO
2
System: Yes No Date Last Serviced:
Safety Equipment: Life Jackets for All Persons: Yes No Survival Suits: Yes No
Certified Life Raft: Yes No Additional Equipment:
Galley: Cooking Stove Fuel: Fire Extinguisher Present: Yes No
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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