London International Marine Limited

Astra House, Southfields Business Park, Laindon, Essex, SS15 6TQ, United Kingdom

Tel: 00 44 845 890 1565

MARINE YACHT HULL & MACHINERY INSURANCE PROPOSAL FORM
Insured’s Name : / Address:
Vessel Name:
Date cover required from:
Covers Required : / Sum Insured
Hull & Machinery
War Risks
Tender
Personal Property
Medical Expenses
Uninsured Boaters
Protection & Indemnity
Crew Liability
Passenger Liability(Charter Only)
Pollution Liability
Electronics
Towing
Trailer
Navigation details :

Vessel Details

Is the vessel used for Private and Pleasure use or Charter Hire
Is the vessel powered by Motor or Sail
What is the Vessel Length
Who was the Builder
In what year was the vessel built
What is the Maximum Designed Speed (MPH or Knots)
What are the Engines (number and type)
Additional details:
Does the Vessel have any Surface Drives / YES / NO
What is the hull construction type
What is the Class
The Vessel Flag
If Flag USA, please state county of registration
The mooring Country
If moored in USA, in which State
If moored in Florida, in which County
Where is it normally moored
In what Berth Number
How many Crew do you have
Professional crew / YES / NO
If YES please provide additional details :
Name of Beneficial owner if different to the Insured name:
Insured’s occupation
Insured Date of Birth (DD/MM/YYYY)
Purchase price of the vessel
Purchase date of the vessel
Details and experience of any other operators of the vessel
Details of any outstanding Mortgage on the vessel
Any Automatic Fire Extinguishers?
Details is applicable:
Is the vessel diesel powered only (sailing yachts) / YES / NO
Is there any racing / rally use / YES / NO
If YES please provide additional details :
Is there any water skiing/diving use
If YES please provide additional details :
Is the vessel a catamaran / YES / NO
Is the vessel a trimaran / ferro / YES / NO
Is a survey of the vessel available? If yes, please send a copy to us via e-mail / YES / NO
Please supply details of the vessels Anti-Theft Precautions

Navigation Details

Do you navigate in Inland waters only / YES / NO
If NO please provide additional details :
Are you intending to navigate around New Zealand / Australia / YES / NO
If YES please provide additional details :
Are you intending to navigate around the Mediterranean Sea / Europe / YES / NO
If YES please provide additional details :
Are you intending to navigate around the West Coast of USA / Mexico / YES / NO
Are you intending to navigate around North of Cabo San Lucas from 15/06 to 15/10 / YES / NO
Are you intending to navigate around Chesapeake Bay and North from 01/06 to 01/11 / YES / NO
Are you intending to navigate around Cuba / Columbia / Haiti / Venezuela / YES / NO
Are you navigating single handedly / YES / NO
Will there be any Trans Pacific navigation (one way) / YES / NO
If YES please provide additional details :
Will there be any Trans Pacific navigation (return) / YES / NO
If YES please provide additional details :
Will there be any Trans Atlantic navigation (one way) / YES / NO
If YES please provide additional details :
Will there be any Trans Atlantic navigation (return) / YES / NO
If YES please provide additional details :
Will there be any Indian Ocean navigation (one way) / YES / NO
If YES please provide additional details :
Will there be any Indian Ocean navigation (return) / YES / NO
If YES please provide additional details :
Will there be any Hawaii navigation (one way) / YES / NO
If YES please provide additional details :
Will there be any Hawaii navigation (return) / YES / NO
If YES please provide additional details :
Will there be any Bermuda navigation (one way) / YES / NO
If YES please provide additional details :
Will there be any Bermuda navigation (return) / YES / NO
If YES please provide additional details :
Will there be any Panama transit (one way) / YES / NO
If YES please provide additional details :
Will there be any Panama transit (return) / YES / NO
If YES please provide additional details ::

Claims Details

Have you ever had a CCJ / Debt Judgement or been made bankrupt during the last five years? / YES / NO
If YES please provide additional details :
Have you ever been refused insurance, had special terms imposed or had a policy cancelled? / YES / NO
If YES please provide additional details ::
Have you any current convictions, police cautions or pending prosecutions (other than motoring convictions)? / YES / NO
If YES please provide additional details :
Have you 3 years experience and no claims in the last 5 years / YES / NO
If NO please provide additional details :
If claims have occurred, were they no fault claims? / YES / NO
Details of claim:
Do you possess a recognised yachting qualification / YES / NO
If YES please provide additional details :

Cover Details

Law & Practice Jurisdiction / English / USA
Will you be Laying-up the vessel / YES / NO
If YES please provide additional details :
Do you wish to cover for lightning strikes / YES / NO
Do you require windstorm cover in "the Box" / YES / NO
If YES please provide additional details :
Additional information :
Signed
Name
Date

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