NEWS Insurance Services Inc.

Luxury Yacht Application Form

1501 Westcliff Dr. Suite 301
Newport Beach, CA. 92660
Tel: 877-700- NEWS
Fax: 949-554-0250
Email: Info@newsinsurance.com
Web: www.newsinsurance.com

Section 1 - OWNER / BENEFICIAL OWNER INFORMATION

Owner / Beneficial Owner Name *

Date of Birth *

Occupation *

Home Address

Telephone

Fax

Cell phone

E-mail

Mailing Address (if different from above)

If Corporately Owned :

Company Name

Main Contact Person

Address

Telephone

Fax

Cell phone

E-mail

Section 2 - OWNER EXPERIENCE & LOSS HISTORY

Previously Owned Vessels

(Manufacturer Model / Size)

Has Insurance for Any Vessel Ever Been Declined, Non-Renewed or Cancelled ? Yes No

If "YES", Why?

Has the Owner and/or the Captain Ever Suffered Any Losses ? Yes No

If "YES", Detail the Date, Cause, Nature and Amount of Loss

Current / Previous Insurer :

Section 3 - VESSEL INFORMATION

Vessel Name

Year Built

Hull Material

Manufacturer / Model

Length

Hull ID

Is the Vessel equipped with a helicopter landing pad? Yes No

Section 4 - TRAILERS / TENDERS / PWC / TOYS

Trailer Manufacturer / Model	Year Built	Serial #	Value
Tender(s) Manufacturer / Model / Length	Year Built	Engine Manufacturer / HP	Value
Tender(s) Manufacturer / Model / Length	Year Built	Engine Manufacturer / HP	Value
Tender(s) Manufacturer / Model / Length	Year Built	Engine Manufacturer / HP	Value
Tender(s) Manufacturer / Model / Length	Year Built	Engine Manufacturer / HP	Value
Will any Tender(s) More Than 25Ft. in Length be Towed Yes No
If "YES" pls. provide Details
PWC Manufacturer / Model	Year Built	Engine Manufacturer / HP	Value
PWC Manufacturer / Model	Year Built	Engine Manufacturer / HP	Value
List all Toys incl.(Fishing, Equipment, Scuba Gear etc.) Item	Value	Item	Value
Item	Value	Item	Value

Section 5 - PRIMARY BERTHING LOCATION / NAVIGATION / VESSEL USE

Primary Berthing Location *

(if different in Summer/Winter, pls. note both locations)

Name of Marina

City

State

Zip Code

Country

Intented Navigation for Insured Period

Private Pleasure Occasional Charter Full Time Charter

Is Vessel Used for Racing (other than local Club Racing) Yes No

If "YES", provide details

Section 6 - VESSEL OPERATION / CREW

Is the Vessel Exclusively Owner Operated Yes No

If "NO", list Name, Age an Experience of all other individuals Who Operates the Vessel

Does the Vessel Employ Professional Paid Crew Yes No

If "YES", Name of the Captain

Total Number of Crew : Full Time : Occasional :

Section 7 - REQUESTED INSURANCE COVERAGE

Expected Commencement Date

COVERAGE TYPE	COVERAGE LIMIT
Yacht Hull & Machinery (incl. equipment/Contents/Toys)	$
Personal Effects	$
Fine Arts	$	max per item, $
Tender(s) / PWC(S)	$
Trailer(s)	$
Liability (P&I) incl. Coverage for Crew	$
Medical Expenses	$
Uninsured Boaters	$
Requested Hull & Machinery Deductible Option(s)
Does the Vessel currently have a separate Named Windstorm Deductible Yes No
If "YES", what is the Deductible Amount

Section 8 - ADDITIONAL INTERESTS

Name

Address

Type of Interest

Loss Payee Additional Insured Breach Warranty

Note Amount of Loans : $

Section 9 - PRODUCER INFORMATION

Producer Name

Producer Address

Producer Code

Name of the Contact Person

Telephone No.

Fax No.

Cell phone

E-Mail

Sales Agent: