FXM Risk – Yacht Insurance Application

Applicant Information

Insured's Name Full Mailing Address Beneficial Owner

Effective Date From

Vessel Information

Vessel Name

Hull ID

Length (ft)

Year Built

Manufacturer / Model

Maximum Speed (Knots)

Purchase Price

Present Value

Date of Purchase

Vessel Flag

Requested Coverages

Hull Physical Damage Limit Tender / Dinghy Medical Payments Personal Property Trailer Breach of Warranty (Loss Payee Required) Third Party Liability Paid Crew Liability Commercial Passenger Liability Uninsured Boaters Other Coverage

Vessel Specifications

Primary Power

Vessel Type

Hull Material

Fire Prevention & Extinguishing Equipment Date of Last Survey Survey Provided to Underwriters?

FXM Risk – Yacht Insurance Application

Applicant Information

Vessel Information

Requested Coverages

Vessel Specifications

Operator Information (Named Operator Policy)

Operator 1

Operator 2