WATERCRAFT FORM
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
Has the Owner and/or the Captain Ever Suffered Any Losses ? Yes No
If "YES", Detail the Date, Cause, Nature and Amount of Loss

 
 
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