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F16213A (9-03).p65 (RT Specialty)

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F.16213A (1/04)
OCEAN MARINE APPLICATION
Boat Dealer/Marina Operator
F.16213A (1/04)
❏ Great American Insurance Company of New York
❏ Great American Insurance Company
❏
NAME OF APPLICANT PRODUCER NAME AND ADDRESS
ADDRESS - NUMBER AND STREET
CITY STATE ZIP
LOCATION OF YARD (BUILDINGS)
A.
B.
C.
PRESENT INSURANCE CARRIER REASON BEING REPLACED
PRODUCER CURRENT AGENT OF RECORD? CURRENT PREMIUM
❏ Ye s ❏ No
EXPIRATION DATE OF CURRENT POLICY REQUESTED ATTACHMENT DATE
YEARS IN BUSINESS HAS INSURANCE EVER BEEN CANCELED?
❏ Ye s ❏ No
EXPERIENCE OF PRINCIPALS
LOCATION A LOCATION B LOCATION C
U/L Certified Central Station Alarm ❏ Ye s ❏ No ❏ Ye s ❏ No ❏ Ye s ❏ No
Alarm with outside siren ❏ Ye s ❏ No ❏ Ye s ❏ No ❏ Ye s ❏ No
Complete fence and floodlight ❏ Ye s ❏ No ❏ Ye s ❏ No ❏ Ye s ❏ No
Watchman service with clock ❏ Ye s ❏ No ❏ Ye s ❏ No ❏ Ye s ❏ No
Owner lives on premises ❏ Ye s ❏ No ❏ Ye s ❏ No ❏ Ye s ❏ No
Bubble system ❏ Ye s ❏ No ❏ Ye s ❏ No ❏ Ye s ❏ No
Paid fire protection ❏ Ye s ❏ No ❏ Ye s ❏ No ❏ Ye s ❏ No
Miles from fire station Miles Miles Miles
Public fire hydrants - number and distance
Describe any private fire protection:
MARINA OPERA
TOR
This is not a Binder
BOAT DEALER/
Submit Application
$
Reset
F.16213A (1/04)
Section I - Boat Dealer
PROPERTY DAMAGE LIMIT
Location A. Location B. Location C.
LIABILITY LIMIT DEDUCTIBLE
MORTGAGEE NAME AND ADDRESS
PROPERTY SOLD MANUFACTURERS
Power boats
Sail boats
Accessories
Motors
Trailers
LAST INVENTORY DATE AVERAGE-MONTHLY INVENTORY MAXIMUM MONTHLY INVENTORY
Location A. Inside
Outside
In Water
Location B. Inside
Outside
In Water
Location C. Inside
Outside
In Water
BOATS DELIVERED (LAND OR WATER)
Total Annual Values = Number of boats Highest value boat
Maximum miles over land Maximum miles over water
DEMONSTRATIONS (JET SKIS AND WAVERUNNERS ARE NOT COVERED)
Number per month Maximum MPH on boats
Where are demonstrations performed? Miles from shore
All U.S. Coast Guard safety equipment on board
Employees trained in use prior to demonstration
Explain:
BOAT SHOWS
Number of shows annually Maximum Number of boats each show Maximum limit required per show
TRANSPORTED BY MAXIMUM DISTANCE TO SHOWS
❏ Common carrier ❏ Owned vehicles ❏ Both
❏ All land ❏ All water ❏ Land and water miles
$
$
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$
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$
F.16213A (1/04)
Section II - Marina Operator
REQUESTED LIMIT DEDUCTIBLE
ACTIVITY ANNUAL GROSS RECEIPTS
Repairs/alterations $
Dry storage $
Mooring/docking rentals $
Fueling $
Hauling and launching $
Other service receipts (type) $
Total $
REPAIR OPERATIONS
Type of Vessels Repaired Type of Work
Highest value any Average value Are boat owners allowed to
one boat repaired of boat repaired work on their own boats? ❏ Ye s ❏ No
Describe any non-private pleasure boat repairs and amount of receipts:
DRY STORAGE
LOCATION A. LOCATION B. LOCATION C.
Maximum value stored inside
Maximum value stored outside
Average monthly value
Number of boats stored
Are boats stored in racks? ❏ Ye s ❏ No Number of boats stored afloat between 12/1 and 4/1 =
Winterizing or make ready maintenance part of the storage agreement? ❏ Ye s ❏ No
(Please submit copy of storage agreement with this application)
Describe type of building construction for land storage:
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F.16213A (1/04)
MOORING/DOCKING RENTALS
LOCATION A. LOCATION B. LOCATION C.
Maximum number of slips/moorings to rent
Actual number rented
Maximum value any one boat
Total value of all boats
Do any of the slips have roofs? ❏ Ye s ❏ No How many?
Are any of the slips owned by boat owners? ❏ Ye s ❏ No How many?
HAULING AND LAUNCHING
Number of boats handled last year Type of equipment ❏ Ramps ❏ Cranes ❏
Rated capacity of lifting equipment Frequency of maintenance of equipment
FUELING
Type of fuel sold ❏ Gas ❏ Diesel ❏ Both Are propane tanks refilled on premises? ❏ Ye s ❏ No
Who performs fueling of boats? ❏ Employer ❏ Boat owner ❏ Both Smoking signs posted and enforced? ❏ Ye s ❏ No
OTHER SERVICING
Please describe:
Section III - Owned Watercraft
Applies only to work boats used in conjunction with marina and boat dealer operations. Private pleasure use is not covered.
Schedule of boats Value Deductible
1. 1. 1.
2. 2. 2.
3. 3. 3.
4. 4. 4.
5. 5. 5.
Liability limit requested:* Deductible
Crew coverage required? ❏ Ye s ❏ No If yes, how many? Navigation not to exceed miles from premises.
$
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F.16213A (1/04)
Section IV - Loss History
List all claims or losses (whether or not insured) sustained during the last five years on all operations.
GROSS AMOUNT
CLAIM
TYPE OF LOSS DATE DETAILS BEFORE ANY
DEDUCTIBLE
OPEN CLOSED
REMARKS
LOCATION
OF ACCIDENT
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. (Applicable to New York State only.)
Signing this application does not bind the Applicant to purchase the insurance or the Company to accept the risk, but it is agreed that this
application shall be the basis of the contract should a policy be issued.
APPLICANT SIGNATURE COMPANY TITLE DATE
PRODUCER SIGNATURE COMPANY TITLE DATE
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F.16213A (1/04)
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Completed 13 December 2020

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