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.

2 *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.

3 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?

4 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? (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

5 LOCATIONCITYAFLOATDRYWINTERSUMMERSTATEZI PCOUNTRYSECONDARY BERTH / STORAGE LOCATIONCITYWINTERSUMMERSTATEZIPCOUNTRY$ PRESENT VALUE$COST NEWDATE PURCHASEDMAX SPEEDLENGTHMODELMANUFACTURERYEARTERRITOR YBOAT HULLMOTOR #YEARSERIAL NUMBERMODELMANUFACTURERHORSEPOWERDATE PURCHASED$COST NEW$PRESENT VALUEFUELGASOLINEDIESELBATTERYYEARSERIAL NUMBERMODELMANUFACTURERHORSEPOWERDATE PURCHASED$COST NEW$PRESENT VALUEFUELGASOLINEDIESELBATTERYENGINE / MOTOR#YEARMODELMANUFACTURERSERIAL NUMBER# PURCHASED$COSTTRAILERACORD 82 (2013/09)* MARITAL STATUS / CIVIL UNION (if applicable)EXPLANATION#ANY OPERATOR UNDERGOING A COURSE OF TREATMENT FOR A PHYSICAL / MENTAL IMPAIRMENT?

6 (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?

7 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?

8 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?

9 (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.

10 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. 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 .