NEWS Insurance Services Inc.

Watercraft Insurance Application Form

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

Section 1 - OWNER / BENEFICIAL OWNER INFORMATION

* Mandatory fields

Quote Date

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 :