Address:

City:

State:

Zip Code:

Title:

Phone:

FAX:

E-mail:

Desired Effective Date:

Quote Needed By:

Liability Section:

1. Number of Members / Students:

All Members and Students must sign a Release or Waiver of Liability to be eligible for this insurance. Please attach a copy of your Form.

2. Jones Act Coverage - On the Water #:

If Jones Act Coverage is desired for launch operators, instructors and coaches, the average number on the water at any one time is should be entered in the box above.

3. Rental Boats:
Estimated Gross Receipts $:
(If you rent boats to Members or public)

4. Do you borrow boats?

If yes, what is the aggregate value of the borrowed boats $:

How Often?

5. Do you run or host regattas?

How Many?

6. Season:
(Club is open for rowing- dates:

Supplemental Coverages - (please complete if coverage is desired)

1. Do you rent your storage rack space:

If yes, Please complete Marina Operators Legal Liability Application

2. Do you own docks?

If yes, please complete The Dock Coverage Application

3. Owned Boathouse?

See the attached Application for Building Coverage

Please attach a Schedule of vessels and equipment including: Builder, Year, Model, Hull ID Number, Current Value.

Please put the total values to be insured on the Schedule. Include all watercraft including launches, shells, oars, and outboards to be insured.

Please fill out the Equipment Application, if you have any equipment in addition to the items mentioned above. Lay-up Period during which shells and launches are not on the water (min. 90 days).

Loss History - Do not leave blank, if there have been no claims please state that. Please, show five (5) years of claims as a year by year basis.

Did you have any claims?

Year #1:

Paid Losses:

Outstanding Losses:

Year #2:

Paid Losses:

Outstanding Losses:

Year #3:

Paid Losses:

Outstanding Losses:

Year #4:

Paid Losses:

Outstanding Losses:

Year #5:

Paid Losses:

Outstanding Losses:

USE ADDITIONAL SPACE TO DETAIL
MAJOR LOSSES, UNUSUAL LOSSES, AND RECOVERIES