NEWS Insurance Services Inc.

WaterCraft 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 *

Mailing Address (if different from above)

IF CORPORATELY OWNED :

Company Name *

Address

Section 2 - OWNER EXPERIENCE & LOSS HISTORY

Years Boating

Years as Owner

Has the owner or Captain ever
suffered any losses? *
Yes No

If "yes", detail the Date, Cause, Nature and Amount of Loss *

Has the owner's insurance ever been declined, cancelled or non-renewed? Yes No

Current / Previous Insurer

Section 3 - VESSEL INFORMATION

Vessel Name

Year Built *

Length *

Manufacturer *

Model *

# of Engines *

HP per Engine *

Engine Manufacturer

Year Manufatured

Vessel Purchase Price *

Section 4 - TRAILERS / TENDERS / PWC / TOYS

Trailer Manufacturer / Model

Value

Tender(s) Manufacturer / Model / Length

Year Built

Engine Manufacturer / HP

Value

PWC Manufacturer / Model

Year Built

Engine Manufacturer / HP

Value

Section 5 - PRIMARY BERTHING LOCATION / NAVIGATION / VESSEL USE

Primary Berthing Location *

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

City

State *

Zip Code

Country

Intented Navigation for Insured Period

Vessel Use 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

Named Operators

D.O.B

Affiliation to Owner

Section 7 - REQUESTED INSURANCE COVERAGE

Expected Comencement Date

COVERAGE TYPE

COVERAGE LIMIT

Yatch Hull & Machinery *
(incl. Equipments/Contents/Toys)

Personal Effects

Fine Arts

max per item, $

Tender(s)/PWC(S)

Trailer(s)

Liability (P&I) incl.
coverage for Crews *

Medical Expenses

Uninsured Boaters

Does the Vessel currently have a separate Named Windstorm Deductible Yes No

If "YES", what is the Deductible Amount : $

Section 8 - ADDITIONAL INTERESTS

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 Contact Person

Phone No.

Fax No.

Cellphone No.

E-Mail

Sales Agent: