Marina/Boat Dealer Insurance Application :: Atlass Special Risks :: a division of Atlass Insurance Group

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MARINA/BOAT DEALER Application
Atlass Insurance Group

* Required
Name of Assured: *
E-Mail: *
Survey Contact/Phone Number: *
Mailing Address:
City, State, Zip
Web Site Address:
Individual Partnership Corporation Other

Producer's Name:
Street Address:
City, State, Zip
1. List and describe any business owned, operated, or managed by the insured, including lessor's risk
2. Number of years in business
3. Proposed effective date
4. Please provide a name of current carriers, explaining premiums, and policy expiration dates
5. Is the insured a subsidiary of any other entity or does the insured have any subsidiaries? If yes, please describe
6. Any policy or coverage declined, cancelled, or non-renewed during the prior three years? If yes, please describe
Locations:

Coverages Requested:
Marina Operators General Liability Protection and Indemnity Boat Dealer's Inventory	Property Insurance Piers, Wharves and Docks Equipment/Tools Owned Watercraft

PLEASE COMPLETE ALL APPLICABLE SECTIONS RECEIPTS AND SALES INFORMATION
Gross Receipts		Gross Sales
Activity	Amount	Types	Amount
Dock Rental	$	Boat Sales	$
Storage	$	Boat brokerage Commissions	$
Repair	$	Ship Store Sales	$
Fueling	$	Restaurant Sales	$
Hauling/Launching	$	Other Sales**	$
Rental (Boats)	$	Total Sales	$
Rental (Leased Property)	$
All other receipts*	$
Total Receipts	$
*Please identify source of other receipts:		**Please identify Source of other sales:

General Information

Protection at location Check Yes or No
U/L certified central station alarm	Yes No
Watchman service after business hours	Yes No
Describe nature and extent of watchman
Alarm with outside gong or siren	Yes No
Completely fenced and floodlighted	Yes No
Automatic/emergency fuel shutoff valve	Yes No

Fire Protection
Paid or volunteer
Distance from location(s)
Public fire hydrants - # and distance
Public fire mains - size and pressure
Describe any private fire protection

Section 1 - Marine Operators Liability

1. Limits requested:
A. Any one vessel
B. Any one accident or occurrence
2. Deductible requested:	(minimum $1,000)

Docking and Mooring

Slips available for rent?
Buoys available for rent?
Average value of yachts
Maximum value of yachts
Any slips under a common roof?
Describe type of heavy lift equipment and indicate lifting capacity

Storage*

Max number of yachts stored at any time in the past year?
Number stored in summer?
Number stored in winter?
Average value of yachts
Max. value of yachts

A. Are yachts stored afloat between 12/1 and 4/1?

B. Are yachts stored inside a building?

If yes, are they on racks? Sprinkler system?

C. Type of building construction

D. Fire rate

E. Are yachts stored outside on racks? If yes, how many?

*If you provide any storage a copy of the storage agreement is required for coverage to apply.

Repair Operations

A. Type of vessels?

B. Type of work?

C. Highest value of any one yacht repaired last year

D. Describe any commercial ship repair work you do and provide receipts

E. Receipts (non-commercial) past 12 months

Section 2 - General Liability

Limits Requested (choose one)	Option A	Option B	Option C
A. General Aggregate B. Products-completed Oop Aggregate C. Personal and Advertising Injury D. Each Occurrence E. Fire Damage (Any One Fire) F. Medical Expense (Any One Person)	$2,000,000 $1,000,000 $1,000,000 $1,000,000 $100,000 $5,000	$1,000,000 $500,000 $500,000 $500,000 $100,000 $5,000	$1,000,000 $300,000 $300,000 $300,000 $100,000 $5,000
Products Sold (ex boats and ship stores) - Annual Sales - # of Units - Intended Use

Explain all "yes" responses in comments box below.	Check Yes or No
1.Does applicant install, service, or demonstrate products?	Yes No
2. Foreign products sold, distributed, used as components?	Yes No
3. Research and development conducted or new products planned?	Yes No
4. Guaranties, warranties, hold harmless agreements?	Yes No
5. Products recalled, discontinued, or changes?	Yes No
6. Products of others sold or repackaged under applicant's label?	Yes No
7. Products under label of others?	Yes No
8. Vendor's coverage required?	Yes No
9. Does any named insured sell to other named insured?	Yes No
10. Products manufactured?	Yes No
Explain all "yes" responses in comments box below. Please include question number with answers
Additional interest/certificate recipients
Name and Address - Interest - Certificate

General Information

Explain all "yes" responses in comments box below.	Check Yes or No
1. Any medical facilities provided or doctor employed/contracted?	Yes No
2. Any exposure to radioactive/nuclear material?	Yes No
3. Do operations involve storing, treating, discharging, applying, disposing or transporting of hazardous material?	Yes No
4. Any operation sold, acquired or discontinued in last five years?	Yes No
5. Any parking facilities owned/operated? Number of parking spaces	Yes No
6. Is a fee charged for parking?	Yes No
7. Recreation facilities provided?	Yes No
8. Is there a swimming pool on the premises?	Yes No
9. Sporting or social events sponsored?	Yes No
10. Any structural alterations contemplated?	Yes No
11. Any demolition exposure contemplated?	Yes No
12. Does harbormaster live on premises?	Yes No
13. Does insured use sub contractors? If so, indicate percentage of receipts	Yes No
Explain all "yes" responses in comments box below. Please include question number with answers

Section 3 - Boat Dealer's Insurance

Request limits:
Limit any one vessels:
Limit any one location:
Limit any one accident or occurrence
Deductible each occurrence each location: (minimum $1,000)
Type of boats and manufacturer

Location:

Last Inventory Date

Prior Inventory* Date*

Average Monthly Inventory

Building Open Area In Water
*Should be six months from prior inventory sale.

Transit Exposures:
Are any boats delivered from mfg. at Insured's risk? If yes, how are they delivered?
Max. value any one boat - Max. Value any one delivery

Are any boats delivered by water to the insured? If yes, from where?

Total value of boats delivered by insured during the past year:

By public carrier

By applicant's vehicle

Average distance the boats are transported?/ Maximum?

Number of boats delivered to purchaser by water

Average distance / Average Value

Boat Shows:
# of boats shown annually - # of boats each show

In water or land

Maximum dollar limit any one show

Average/maximum distance to show

Transported by common carrier or own vehicles?

Demonstrations:
Maximum value any one boat

Maximum mph any one boat

Is boat under command of competent employee?

Are demonstrators equipped with full complement of U.S. Coast Guard required safety equipment?

Section 4 - Piers, Wharves, and Docks

Indicate Valuation - ACV 80% RC 90% Choose one
Number of floating docks
Number of fixed piers
Insured value of docks
Insured value of piers
Email a diagram of the docks/piers if available.
Describe the floating docks and piers:
Indicate type of construction:
Indicate type of floating devices
Indicate type of mooring devices
Age of docks/ Age of piers
Are the slips open or covered?
Number of open slips/ Number of closed slips
Describe the maintenance program
Describe firefighting capabilities
Deductible requested: ($1,000 minimum)

Section 5 - Protection and Liability

Section Applicable Check box if Yes or No	Yes	No
Marina operators
Boat dealers
Work boats			How many?
Rental boats			How many?
Other owned boats (excl. boats for sale)			How many?
Limit requested:
For owned watercraft, are crew covered? If yes, #
Please fully describe work boat/rental boat/other owned boat operation if you are requesting P & I coverage for these vessels

Section 6 - Property Insurance

Premises Information:	ACV (ACV 80%) or Repl Cost (RC 90%)
Location Number	Building Number
Subject of Insurance:	Limit:
Building
Contents
Other
Deductible (minimum $1,000)
Year built
How is this building used by the Insured?
Construction type Protection class RCP Code
Total area Other occupancies
Building improvements
Wiring, yr	Heating, yr.
Roofing, yr	Plumbing, yr. # of stories
Check box Yes or No
Burglar Alarm: Yes No	Describe:
Sprinkler System: Yes No	Describe:
Basement: Yes No
Business Income and Extra Expense Coverage - Actual Loss Sustained Requested LImit COINSURANCE 80%

Section 7 - Equipment/Tools

Equipment Coverage: Indicate Valuation ACV 80% Repl Cost 90%
Complete the following or submit schedule
Description - Value - D/A - Serial Number - Location

Section 8 - Owned Watercraft

Owned Watercraft Coverage: Indicate Valuation ACV 80% Repl Cost 90%
Fully describe any operation for which you are requesting coverage for owned watercraft

Please complete the following or submit a detailed schedule for all watercraft.
Description - Value - D/A - Serial Number - Location

If you are requesting coverage for boats that are rented please submit a copy of the applicable rental agreement as well as a description of your rental qualification standards.

Mortgages/Loss Payees
Name and address - Interest - Coverage Section(s) Applicable - Location

Section 9 - Loss Information

APPLICABLE TO ALL SECTIONS 1 THROUGH 8

Loss Record:
List all claims incurred during the past five years to property or from operations covered by this form of policy, including date, cause, amount paid or estimated amount, if claim not settled. If none, state "none".
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION OF INSURANCE CONTAINING ANY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME.

Signature of Applicant Date

Remarks: