BOAT HULL NO: WATERCRAFT APPLICATION - …

1 acord 82 (2013/09)CIVIL UNION (if applicable) boat hull NO:HEATING# OF EXTINGUISHERSDATE LAST WEIGHEDSIZEDESCRIPTIONTYPEY/NEQUIPMENT TYPE# OF STOVES:FUEL TYPE:SPACES PROTECTED:MODELLIMITSERIAL NUMBERMODELMANUFACTURERYEAREQUIPMENTPORT ABLE ACCESSORIES AND LIFEBOATS / TENDERSMANUFACTURERRATING / UNDERWRITINGCOOKING STOVEFUME DETECTORAUTOMATIC?2CO / CHEMICAL SYSTEMSFIRE EXTINGUISHERSBILGE PUMPSDEPTH SOUNDERRADARRADIO DIRECTION FINDERSHIP TO SHORE RADIOANTI -THEFT DEVICESY/NEQUIPMENT TYPEThis field may not be utilized forpolicyholders applying for residentialproperty insurance in CA.*MARITAL STATUS * /BIRTH DATECO-APPLICANT'S OCCUPATION (State Nature of Business if Self-Employed)APPLICANT'S OCCUPATION (State Nature of Business if Self-Employed)SECONDARY E-MAIL ADDRESS:PRIMARY E-MAIL ADDRESS:PHONE #CELLHOMEBUSPRIMARYPHONE #SECONDARYCELLHOMEBUSDATE AT CURRENT RESIDENCE:APPLICANT'S NAME AND MAILING ADDRESS (Include county & ZIP+4)POLICY NUMBER:EFFECTIVE DATEEXPIRATION DATECARRIERNAIC CODEPLANFACILITY CODEFAX(A/C, No):AGENCYNAME:CONTACT(A/C, No, Ext):PHONESUBCODE:CODE:AGENCY CUSTOMER ID:ADDRESS:E-MAILDATE (MM/DD/YYYY) WATERCRAFT APPLICATION $$$$$$$$$$$$$$$$$$$FORM NUMBERFORM DATEPREMIUMDEDUCTIBLE$$$$$$$$$LIMITTOAPP LIESLIMITTOAPPLIESCODEUNIT #COVERAGEEA PER$$EA ACCEA ACCPDCSL / BI$$$EA ACCEA ACC$EA PERPDCSL / BI$N / A$$$$$$$$$$$$$$$$$$$$$$$EA ACCEA ACC$N / A$$AARCACVFORM NUMBERFORM DATEUNIT #TOTAL.

2 UNINSUREDBOATERS LIABILITYHULL$OUTBOARD MOTOREA PERPDCSL / BI$LIABILITY(Or Protection &Indemnity)MEDICAL PAYMENTSPREMIUMCOVERAGELIMITSDEDUCTIBLEU NDERINSUREDBOATERS LIABILITYCOVERAGES / LIMITS OF LIABILITYPERSONAL EFFECTSTOWINGPORTABLE ACCESSORIESTRAILERHURRICANE HAUL-OUTThe acord name and logo are registered marks of ACORDPage 1 of 5 1992-2013 acord CORPORATION. All rights 82 (2013/09)MOTOR #Page 2 of 5 ARE THERE ANY ADDITIONAL OWNERS NOT LISTED AS THE NAMED INSURED? (If "YES", enter owners in the Additional Interest section) RESIDENCE? (Y / N)NUMBER OF RESIDENTSIS THE boat USED AS A PRIMARY RESIDENCE? EXISTING DAMAGE TO THE boat ? OF BEDSANY SLEEPING FACILITIES? OF PART-TIME CREWNUMBER OF FULL-TIME CREWDOES THE APPLICANT EMPLOY A PAID CREW? THE boat USED FOR WATERSKIING? NAVIGATEDEXTENT OF RACESFREQUENCYIS THE boat USED FOR RACING? THE boat USED COMMERCIALLY OR FOR BUSINESS PURPOSES? (Y/N)ALCOHOLCHARTER? (Y/N)TIMECHARTER?

3 (Y/N)VOYAGECHARTER? (Y/N)BARE BOATFREQUENCYLENGTHDESTINATIONIS THE boat CHARTERED TO OTHERS? / NEXPLAIN ALL "YES" RESPONSESHULL INFORMATIONBOAT hull NO:AGENCY CUSTOMER ID:GULF OF MEXICORIVERSPACIFICINLAND WATERWAYSGREAT LAKESATLANTICWATERS NAVIGATEDCATAMARANVEE BOTTOMROUND BOTTOMFLAT BOTTOMHULL DESIGNHULL MATERIALFIBERGLASSMETALWOODTYPE OF HULLCABIN CRUISEROPEN COCKPITSAILBOATBASSPERSONAL WCSKIPONTOONSAILWATERJETOUTDRIVEINBOARD/ OUTBOARDINBOARDPOWERFIBERWOODCARBONALUMI NUMSPAR MATERIALMETALFIBERGLASSFUEL TANKREGISTRATION NUMBERDATE OF LAST SURVEYHULL IDENTIFICATION NUMBERCOUNTRY OF REGISTRATIONNAME OF BOATNAME OF BENEFICIAL OWNERLOC #LOC #END DATESTART DATELAY-UP PERIODPRIMARY BERTH / STORAGE LOCATIONCITYAFLOATDRYWINTERSUMMERSTATEZI PCOUNTRYSECONDARY BERTH / STORAGE LOCATIONCITYWINTERSUMMERSTATEZIPCOUNTRY$ PRESENT VALUE$COST NEWDATE PURCHASEDMAX SPEEDLENGTHMODELMANUFACTURERYEARTERRITOR YBOAT HULLMOTOR #YEARSERIAL NUMBERMODELMANUFACTURERHORSEPOWERDATE PURCHASED$COST NEW$PRESENT VALUEFUELGASOLINEDIESELBATTERYYEARSERIAL NUMBERMODELMANUFACTURERHORSEPOWERDATE PURCHASED$COST NEW$PRESENT

4 VALUEFUELGASOLINEDIESELBATTERYENGINE / MOTOR#YEARMODELMANUFACTURERSERIAL NUMBER# PURCHASED$COSTTRAILERACORD 82 (2013/09)* MARITAL STATUS / CIVIL UNION (if applicable)EXPLANATION#ANY OPERATOR UNDERGOING A COURSE OF TREATMENT FOR A PHYSICAL / MENTAL IMPAIRMENT? (Not applicable in MT, OR and WI) INSURANCE / CONVICTIONS (Note: Your driving record is verified with the state motor vehicle department and other insurers)IF YES, INDICATE BELOW. ALSO INCLUDEY / NREGARDLESS OF FAULT, OR BEEN CONVICTED OF A MOVING VIOLATION WITHIN THE LASTHAS ANY OPERATOR SHOWN ABOVE HAD A MOTOR VEHICLE OR BOATING ACCIDENT,Y / NAMOUNT OFBI OR DEATHPLACE OFDATE OFDRV#ACCIDENT / CONVICTIONDESCRIPTION OF ACCIDENT OR CONVICTIONACCIDENT / CONVICTIONPROPERTY DAMAGECOURSES? (Y/N)POWER SQUADRONCOURSES? (Y/N)OTHER EDUCATIONUSCGAOWNED# YRSMODELPRIOR boat MAKE#OPERATOR'S EXPERIENCEY / NEXPLAIN ALL "YES" RESPONSESOPERATOR INSURANCE BEEN TRANSFERRED WITHIN AGENCY?

5 THE LAST FIVE (5) YEARS [TEN (10) YEARS IN RHODE ISLAND], HAS ANY APPLICANT BEEN INDICTED FOR OR CONVICTED OF ANY DEGREEOF THE CRIME OF FRAUD, BRIBERY, ARSON OR ANY OTHER ARSON-RELATED CRIME IN CONNECTION WITH THIS OR ANY OTHER PROPERTY ?(In RI, failure to disclose the existence of an arson conviction is a misdemeanor punishable by a sentence of up to one (1) year of imprisonment.) APPLICANT HAD A JUDGEMENT OR LIEN DURING THE PAST FIVE (5) YEARS? APPLICANT HAD A FORECLOSURE, REPOSSESSION, BANKRUPTCY OR FILED FOR BANKRUPTCY DURING THE PAST FIVE (5) YEARS? ANY COVERAGE BEEN DECLINED, CANCELLED OR NON-RENEWED DURING THE LAST THREE (3) YEARS?(Missouri Applicants - Do not answer this question)Y / NEXPLAIN ALL "YES" OTHER INSURANCE WITH THIS COMPANY? (List policy numbers)POLICY NUMBERPOLICY NUMBERLINE OF BUSINESSLINE OF BUSINESSGENERAL INFORMATIONOPERATORS [List all residents and dependents (licensed or not) and regular operators]#NAMESEXMARSTAT * date OF BIRTHLICSOCIAL SECURITY #AUTO DRIVERS LICENSE #STATEOCCUPATIONAGENCY CUSTOMER ID:Page 3 of 5 DESCRIPTION OF SPECIAL EQUIPMENT#ANY OPERATOR HAVE PHYSICAL IMPAIRMENT?

6 (Not applicable in MT and WI) date :Start date :SUSPENSION PERIOD#ANY DRIVERS LICENSE SUSPENDED / REVOKED DURING THE LAST THREE (3) YEARS? IN ARIZONA: BINDERS ARE EFFECTIVE FOR NO MORE THAN 90 DAYS; APPLICABLE IN COLORADO: THE INSURERHAS THIRTY (30) BUSINESS DAYS, COMMENCING FROM THE EFFECTIVE date OF COVERAGE, TO EVALUATE THE ISSUANCE OFTHE INSURANCE POLICY; APPLICABLE IN MARYLAND: THE INSURER HAS 45 BUSINESS DAYS, COMMENCING FROM THEEFFECTIVE date OF COVERAGE, TO CONFIRM ELIGIBILITY FOR COVERAGE UNDER THE INSURANCE POLICY; APPLICABLE INMICHIGAN: THE POLICY MAY BE CANCELLED AT ANY TIME AT THE REQUEST OF THE INSURED. APPLICABLE IN OKLAHOMA: ALLPOLICIES SHALL EXPIRE AT 12:01 AM STANDARD TIME ON THE EXPIRATION date STATED IN THE 82 (2013/09)THIS BINDER MAY BE CANCELLED BY THE COMPANY BY NOTICE TO THE INSURED IN ACCORDANCE WITH THE POLICYCONDITIONS. THIS BINDER IS CANCELLED WHEN REPLACED BY A POLICY.

7 IF THIS BINDER IS NOT REPLACED BY A POLICY,THE COMPANY IS ENTITLED TO CHARGE A PREMIUM FOR THE BINDER ACCORDING TO THE RULES AND RATES IN USE BY THECOMPANY. THE QUOTED PREMIUM IS SUBJECT TO VERIFICATION AND ADJUSTMENT, WHEN NECESSARY, BY THE BINDEREFFECTIVE DATEEXPIRATION DATETIMETHIS COMPANY BINDS THE KIND(S) OF INSURANCE STIPULATED ON THIS APPLICATION . THISINSURANCE IS SUBJECT TO THE TERMS, CONDITIONS AND LIMITATIONS OF THE POLICY(IES) INCURRENT USE BY THE :01 AMNOONCOVERAGE IS NOT BOUNDIF THE "BINDER" BOX TO THE LEFT IS COMPLETED, THE FOLLOWING CONDITIONS APPLY:THIS BINDER MAY BE CANCELLED BY THE INSURED BY SURRENDER OF THIS BINDER OR BYWRITTEN NOTICE TO THE COMPANY STATING WHEN CANCELLATION WILL BE , AT THIS OR ANY LOCATION?ANY LOSSES, WHETHER OR NOT PAID BY INSURANCE, DURINGTHE LASTAPPLICANT'SINITIALS:IF YES, INDICATE BELOWY / NLOSS HISTORY(Y / N)DISPUTEIN(C)OMPANY(A)GENTLOSS TYPE$$$ENTERED BYDESCRIPTION OF LOSSLOSS DATEAMOUNT PAIDCAT #SEND BILLREFERENCE / LOAN #:ITEM:CLASS:ITEM DESCRIPTIONINTEREST IN ITEM NUMBERLOCATION:BUILDING:VEHICLE: boat :ITE MEVIDENCE:RANK:CERTIFICATEINTERESTNAME AND ADDRESSADDITIONAL INSUREDLOSS PAYEEMORTGAGEELIENHOLDERTRUSTEEADDITIONA L INTEREST (Attach acord 45, Additional Interest Schedule, if more space is required)SEND BILLREFERENCE / LOAN #:ITEM:CLASS:ITEM DESCRIPTIONINTEREST IN ITEM NUMBERLOCATION:BUILDING:VEHICLE: boat :ITE MEVIDENCE:RANK:CERTIFICATEINTERESTNAME AND ADDRESSADDITIONAL INSUREDLOSS PAYEEMORTGAGEELIENHOLDERTRUSTEEPAYMENT PLAN (Attach acord 610, Premium Payment Supplement, if additional information is required)FINANCE COMPANYY/NPREMIUM FINANCED ?

8 MORTGAGEEINSUREDPAYORPRE-AUTHORIZED DRAFT/CHECK (PAC)PAYROLL DEDUCTIONEFTCREDIT CARDCHECKCASHPAYMENT METHODMONTHLYBI-MONTHLYQUARTERLYSEMI-ANN UALANNUALFULL PAYPAYMENT PLANMAIL POLICY TO:AGENTINSUREDAGENCY BILLDIRECT BILL - ACCTDIRECT BILL - POLICYBILLINGBILLING ACCOUNT #:EST TOTAL PREMIUM:DEPOSIT AMOUNT:$$NO PRIOR COVERAGE$$$$PER ACCIDENTPER PERSONPRIOR POLICY NUMBERPRIOR CARRIERPRIOR COVERAGELINE OF BUSINESSBI OR CSL LIMIT(S) IF APPLICABLEEXPIRATION DATEMOTOR VEHICLE REPORTREMARKS / ATTACHMENTS ( acord 101, Additional Remarks Schedule, may be attached if more space is required)COAST GUARD CERTIFICATEINSPECTIONSURVEYAPPRAISALSTAT E SUPPLEMENT(S) (if applicable)PHOTOGRAPHAGENCY CUSTOMER ID:Page 4 of 5 Applicable in PR: Any person who knowingly and with the intention of defrauding presents false information in an insurance APPLICATION , orpresents, helps, or causes the presentation of a fraudulent claim for the payment of a loss or any other benefit, or presents more than oneclaim for the same damage or loss, shall incur a felony and, upon conviction, shall be sanctioned for each violation by a fine of not less thanfive thousand dollars ($5,000) and not more than ten thousand dollars ($10,000), or a fixed term of imprisonment for three (3) years, or bothpenalties.

9 Should aggravating circumstances [be] present, the penalty thus established may be increased to a maximum of five (5) years, ifextenuating circumstances are present, it may be reduced to a minimum of two (2) in OR: Any person who knowingly and with intent to defraud or solicit another to defraud the insurer by submitting anapplication containing a false statement as to any material fact may be violating state in NJ: Any person who includes any false or misleading information on an APPLICATION for an insurance policy is subject tocriminal and civil in ME, TN, VA and WA: It is a crime to knowingly provide false, incomplete or misleading information to an insurance companyfor the purpose of defrauding the company. Penalties (may)* include imprisonment, fines and denial of insurance benefits. *Applies in in KY, NY, OH and PA: Any person who knowingly and with intent to defraud any insurance company or other person files anapplication 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 subjects such person to criminaland civil penalties (not to exceed five thousand dollars and the stated value of the claim for each such violation)*.

10 *Applies in NY in KS: Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge orbelief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written statement as part of, or insupport of, an APPLICATION for the issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim forpayment or other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows to containmaterially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any factmaterial thereto commits a fraudulent insurance in FL and OK: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim oran APPLICATION containing any false, incomplete, or misleading information is guilty of a felony (of the third degree)*.