Fillable High Performance Boat Insurance Application (Risk Placement Services, Inc.)

Fill Online, Printable, Fillable, Blank High Performance Boat Insurance Application (Risk Placement Services, Inc.) Form

Use Fill to complete blank online RISK PLACEMENT SERVICES, INC. pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

High Performance Boat Insurance Application (Risk Placement Services, Inc.)

On average this form takes 41 minutes to complete

The High Performance Boat Insurance Application (Risk Placement Services, Inc.) form is 3 pages long and contains:

  • 2 signatures
  • 16 check-boxes
  • 148 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Risk Placement Services, Inc. forms online.

BROWSE RISK PLACEMENT SERVICES, INC. FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
QUOTE NUMBER:
PRODUCER INFORMATION
Producer ID Number:
Producer Phone Number:
Producer Fax Number:
APPLICANT INFORMATION
Primary Phone Number:
Secondary Phone Number:
Social Security Number:
Titled Owner? Yes No If no, please explain: Corporately Titled?
Yes No
Residence Is: Owned
Rented
Current Employer & Occupation (If self-employed, provide type of business):
BOAT INFORMATION
HULL TYPE PROPULSION LENGTH WEIGHT MAX SPEED HULL MATERIAL FUEL TYPE
PROPERTY YEAR
MANUFACTURER
NAME
MODEL HULL ID # / SERIAL #
PURCHASE
DATE
PURCHASE
PRICE
CURRENT
VALUE
VESSEL
Total HP:
[ # of ]
ENGINES
Serial #’s:
TOTAL VALUE OF VESSEL,
EQUIPMENT & ENGINE(S):
TRAILER
Year: Manuf: Model: Serial #:
TRAILER VALUE:
BOAT
HOUSE
Description:
BOAT HOUSE
VALUE:
Safety Equipment: Monitoring System Radar High Water Alarm Outboard/Outdrive Locks
Electronic Burglar Alarm Auto Fire Extinguisher Propeller Hub Locks Trailer Ball or Axle Locks
BOAT NAVIGATION LIMITS & USAGE
Navigation Limits:
Offshore
Navigation Distance:
How often will the boat be trailered to
the area of use? Times/Year
One Way Distance: Miles
Type of Vehicle Used to Tow the Boat:
Make:
Model:
BY SIGNING THIS APPLICATION, I WARRANT THAT THE
VEHICLE HAS A TOW CAPACITY RATING THAT IS
ADEQUATE TO PULL THE BOAT AND TRAILER
BOAT STORAGE INFORMATION
MOORING LOCATION OF VESSEL IN SEASON – Address, City, State, Zip –
Marina Name (If applicable)
LOCATION TYPE:
LAY-UP DATES – FROM: TO:
LOCATION:
LOCATION TYPE:
For Transit & Storage Only Policy (no navigation extended) – Storage Location:
Radius of transit from storage location:
High Performance Boat Insurance Application
BINDING: This is an application for insurance. You must submit a fully completed
application and premium to our office in order for coverage to be considered.
OPERATOR INFORMATION
Named Operator Endorsement Applies
—
Please Complete Experience Information For Each Operator
PRIMARY Operator Name Date of Birth
Driver’s License #
& State
Yrs Boating
Experience
Yrs Of Boat
%
Use
Relationship
To Owner
Year Length Manufacturer & Model Max Speed Cat Hull Dates Operated Owned
Y / N Y / N
Y / N Y / N
PRIOR
BOATS YOU
HAVE
OPERATED
Y / N Y / N
Licenses obtained or boating courses completed:
Describe ALL prior marine losses. List and describe all motor vehicle violations and accidents in the past 3 years. If none, state “None”.
SECONDARY Operator Name Date Of Birth
Driver’s License #
& State
Yrs Boating
Experience
Yrs Of Boat
Ownership
%
Use
Relationship
To Owner
Year Length Manufacturer & Model Max Speed Cat Hull Dates Operated Owned
Y / N Y / N
Y / N Y / N
PRIOR
BOATS YOU
HAVE
OPERATED
Y / N Y / N
Licenses obtained or boating courses completed:
Describe ALL prior marine losses. List and describe all motor vehicle violations and accidents in the past 3 years. If none, state “None”.
ELIGIBILITY QUESTIONS
Does the boat have an over the transom exhaust?
Yes No
Have the boat or engine(s) been modified or altered from their stock condition?
Yes No
Is this vessel currently up for sale?
Yes No
During the past 3 years, have any operators had their driver’s license suspended, revoked or refused, been involved in an automobile accident or been convicted of
a moving violation? (If yes, please explain below.)
Yes No
During the past 3 years, has any operator had any boat or automobile insurance canceled, been refused issuance or renewal or received notice of such intent? (If
yes, please explain below. MO residents need not answer.)
Yes No
Have the owner(s) or any operator(s) ever been convicted of a felony? (If yes, please explain below.)
Yes No
REMARKS:
LOSS PAYEE INFORMATION ADDITIONAL INTEREST INFORMATION
Name and Address Name and Address
Explain Interest:
COVERAGES & PREMIUMS: UNIT 1
COVERAGES LIMITS / VALUE DEDUCTIBLE PREMIUM
UNIT PREMIUM:
NOTE: Premium on Total Losses may be fully earned TOTAL TAXES OR FEES:
MINIMUM WRITTEN PREMIUM: TOTAL PREMIUM:
APPLICANT’S STATEMENT AND SIGNATURE
This notice is given in compliance with the Federal Fair Credit Reporting Act (Public Law 91-508) and the Consumer Credit Reform Act of 1996. I
understand that as part of the Company’s underwriting procedure, a routine inquiry may be made which will provide applicable information concerning
character, general reputation, personal characteristics, mode of living and driving record. Upon written request, additional information as to the scope of the
report, if one is made, will be provided.
I have read this application and the entries on it. I understand that if my watercraft is used for any business or commercial purposes, is used in any official
or pre-arranged race, contest or event, is rented or leased to others, or is being held for sale, that this type of usage will void the obligation of the Company
to cover any claims that might occur. I understand that if an ACV policy is purchased, the maximum limit for hull coverage is the actual cash value (ACV) at
the time of the loss or the stated ACV above, whichever is less. The foregoing statements made and signed by the owner(s) represents the information set
forth as correct and a true basis on which insurance may be granted but in no way binds the applicant to accept quotation or insurers to accept risk.
FRAUD WARNING: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of
defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits. Your state may have specific warnings
against filing false claim information. If your boat is located in AZ, CA, NY, OR or PA, please read state specific fraud warnings below.
AZ
For your protection Arizona law requires the following statement to appear on this form. Any
person who knowingly presents a false or fraudulent claim for payment of a loss is subject to
criminal and civil penalties.
CA
For your protection California law requires the following to appear on this form: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR
FRAUDULENT CLAIM FOR PAYMENT OF A LOSS IS GUILTY OF A CRIME AND BE SUBJECT TO FINES AND CONFINEMENT IN STATE
PRISON.
NY
Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim
containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a
fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim
for each such violation.
OR
Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement
in state prison.
STATE SPECIFIC
FRAUD WARNINGS
PA
Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of a claim
containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a
fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.
AK
In connection with this application for insurance, we will review the unit owner’s credit report or obtain or use a credit-based insurance score based on
the information contained in that credit report. We may use this information to decide whether to insure you or how much to charge. We may use a third
party in connection with the development of your insurance score.
CT
In connection with this application for insurance, we will review the unit owner’s credit report or obtain or use a credit-based insurance score based on
the information contained in that credit report. We may use this information to decide whether to insure you or how much to charge. We may use a third
party in connection with the development of your insurance score.
KS
To offer you an accurate quote in connection with this application for insurance we will review the unit owner’s credit report or obtain or use a credit-
based insurance score based on the information contained in that credit report. We may use a third party in connection with the development of your
insurance score. Future reports may be used to update or renew your insurance. The company has established an internal appeal process allowing you to
provide documentation to establish the existence and duration of personal circumstances justifying that certain adverse credit information not be used.
NM
In connection with your application for insurance coverage, we may review and use information contained in the unit owner’s credit report to help
determine your premium or your eligibility for coverage. Future reports may be used to update or renew your insurance.
NY
In connection with this application for insurance, we will review the unit owner’s credit report or obtain or use a credit-based insurance score based on
information contained in that report. An insurance score uses information from the credit report to help predict how often you are likely to file claims
and how expensive those claims will be. Typical items from a credit report that could affect a score include, but are not limited to, the following:
payment history, number of revolving accounts, number of new accounts, the presence of collection accounts, bankruptcies and foreclosures. The
information used to develop the insurance score comes from the following consumer reporting agencies: Experian, TransUnion, or Equifax. Future
reports may be used to update or renew your insurance.
STATE SPECIFIC INSURANCE SCORE NOTIFICATIONS
WV
Your credit information is used by Markel American Insurance Company to produce a credit score. This credit score has an effect on the premium that
you pay for your insurance. Markel American Insurance Company is required by the Insurance Commissioner to recheck your credit information no less
than once every 36 months for changes. You have the option to request that Markel American Insurance Company recheck your credit score more
frequently than once every 36 months, but you can only make this request once during any twelve-month period. If there has been a change in your credit
score, Markel American Insurance Company shall re-underwrite and re-rate the policy based upon the current credit report or credit score. The change in
your credit score may result in an increase or a decrease in the premium that you pay for your insurance. Any changes in your premium will take place
upon renewal if your request is made at least 45 days before your renewal. If the request is made less than 45 days before your renewal date, the insurer
shall re-underwrite and re-rate the policy for the following renewal.
Applicant ‘s Signature: ________________________________________________________ Date: _______________
Producer’s Signature: _________________________________________________________ Date: _______________
Producer’s Name (please print)_____________________________________________________________ Producer’s License No. (required in FL) __________________________
click to sign
signature
click to edit
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

High Performance Boat Insurance Application (Risk Placement Services, Inc.)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 30 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document