MARKEL AMERICAN INSURANCE COMPANY POWERBOAT SELF SURVEY EVALUATION FORM

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1 Our records reflect that a Condition and Value survey is due for your boat. A Condition and Value survey performed by a competent marine surveyor is the best way to determine if there are any defects or problems with your boat that could create a safety hazard or lead to a physical loss. Because your boat is still relatively new, we have provided this self survey form as an alternative to a professional Condition and Value survey. However, completing this form is not a guarantee that a Condition and Value survey will not be required if we deem it necessary. This form asks a number of technical questions that require you to inspect your boat and truthfully report its condition. Please answer all of the questions. Additional comments can be added as an addendum. Photographs of certain areas of your boat are required. Details regarding the photographs are outlined at the end of the questionnaire. Additionally, we ask you to act to correct any problems that are identified through your inspection. If for any reason you are unable to complete this self survey, please contact your agent and they will help you find a local SAMS or NAMS surveyor. Use of this self survey form does not alter or waive any policy conditions, nor does it change any of the rights and obligations related to the contract of insurance. This document is intended for powerboats only. Use back of page to explain answers if needed. General: Date of Self Survey: Name: Policy #: Boat Manufacturer: Model: Hull Number: Registration /Documentation #: How many days do you expect to use your boat this year? Where will you typically navigate? Where is your boat kept?...wet Slip Mooring Boat Lift Dry Stack Trailer Boat Storage Location? Explain anti-theft safety measures in use: Size and age of docking lines: Is anti-chafing gear used?...yes No Where is your boat kept if Laid-Up for winter? Has there been any major work performed to the hull, machinery, electrical or plumbing systems?...yes... No Has the boat been involved in any accidents or losses that have not been reported to your Agent/Insurer?...Yes... No Is the boat currently for sale?...yes... No Has a professional marine surveyor ever inspected this boat?...yes... No Please attach a copy of any previous Condition and Value or Pre-purchase survey you have. MHY Copyright 2010 American Underwriting Managers Agency, Inc. Page 1 of 5

2 Please explain in detail regarding any Yes answers above: Hull: Anti-Fouling Bottom Paint:...Yes No Date of last haul-out? Date of last re-coat: Any stress cracks, blistering, loose hardware, leakage or staining to hull?...yes No Are the stanchions properly bedded?...yes No Has the hull above the waterline been refinished/repainted?...yes No Are all thru-hull fittings and valves clean and operational?...yes No Are wooden plugs tethered at each thru-hull fitting in case of failure or leakage? Yes No Please provide an overview of the hull condition: Age of any and all canvas covers and enclosures: Using portable heating sources (space heaters) is a common source of fire. Never use these unless the boat is attended. Failure to keep through hull penetrations properly sealed can lead to water ingress causing core material, bulkhead and stringer deterioration as well as other ancillary problems. We strongly recommend you have your boat checked for excess moisture. Bilge: Is bilge clean, dry and free of debris?...yes No Are all bilge pumps operational?...yes No Are the bilge pumps supplemented with auto-float switches?...yes No Are the auto-float switches operating properly?...yes No Are the bilge pump hoses pliable without evidence of chafing, cuts or cracking? Yes No Is vessel equipped with an operational high water alarm?...yes No Describe the number and locations of bilge pumps: How often do the bilge pumps cycle? times per hour times per day. How long are pumps operating during cycle? minutes hours How long have the bilge pumps/auto-float switches been in service? Please explain in detail regarding any No answers above: Bilge pumps, switches and the connections should be tested and frequently monitored to ensure proper performance to evacuate water. Bilge pumps are often found to be a secondary source of why boats take on water and sink. MHY Copyright 2010 American Underwriting Managers Agency, Inc. Page 2 of 5

3 Power Engine(s) Make: Model: Hours: Generator(s) Make: Model: Hours: Engines and Generators are:...gas Diesel Drive Type:...Inboard Outboard I/O Jet Other: Condition of engine belts & hoses:...good Fair Poor Are water pump impellers changed at regular intervals...yes No Are oil and fuel filters changed at regular intervals...yes No Are all sea strainers clean and free of debris?...yes No Are engines, machinery and exhaust components free of rust staining?...yes No Are engines, machinery and the space around free of oil and fuel residue?...yes... No Do engines run without vibration during normal use?...yes No Are all components, including starters and alternators marine grade?:...yes No Inboard/Outboard Only: Date the last time outdrive(s) were removed for maintenance: Condition of all bellows:...good Fair Poor (Good = like new & flexible; Fair = slightly worn, starting to harden; Poor = brittle and/or dry rotted) Inboard Only: Date the last time propeller shaft log packing, rudder packing & cutlass bearings were checked or serviced: Please provide general overview or elaborate on any conditions relative to your machinery: Please explain in detail regarding any No answers above: Provide an overview of maintenance and/or repairs performed over last 6 months: Many problems can occur from improper engine maintenance. One of the more typical issues is failure to properly maintain the cooling system. This will cause the motors to overheat, which may require rebuilding or replacement. Exhaust components including manifolds and risers degrade with time and use. Exhaust failure can lead to water ingress into the motors which typically require substantial engine rebuilding or replacement. Additionally, exhaust leaks can cause substantial internal damage to diesel engines. Exhaust leaks will also allow carbon monoxide to escape which is dangerous to passengers. Failure to use marine grade components (usually starters & alternators) is very dangerous and may cause explosion/fire. Have your engines checked regularly by an engine expert. Failure to do routine inspections and properly maintain these items can result in water incursion. Check your engine compartment often, especially after every voyage to ensure condition. MHY Copyright 2010 American Underwriting Managers Agency, Inc. Page 3 of 5

4 Electrical: Number of batteries vessel is equipped: Age of batteries: Are batteries secured in boxes and terminals covered?...yes No Are all circuits protected by operational circuit breakers and/or fuses?...yes No If so equipped, are shore power cable and sockets in good condition?**...yes No Age of shore power cable: Is the wiring safely bundled and routed throughout entire vessel?...yes No Please provide general overview or elaborate on any conditions relative to your electrical systems: Make sure that your batteries have sufficient capacity to keep your bilge pumps running at full capacity. **Shore power cables must be replaced if there are any signs of carbon arching (black across plug face). Failure to replace can lead to fire. Safety: Is vessel equipped with the required: the required type and number of PFDs?...Yes No the required Visual Distress Signals?...Yes No the required Natural or Powered Ventilation?...Yes No the required Backfire Flame Control? (Gas Inboard & I/O only)...yes No the required Sound Producing Devices / Bell?...Yes No the required Navigation Lights?...Yes No the required Pollution Placard?...Yes No the required Marine Sanitation Device?...Yes No the required Portable Fire Extinguishers?...Yes No a Fixed Fire Extinguisher system?...yes No Date when fire extinguishers were last inspected/weighed: Is vessel equipped with operational carbon monoxide detectors?...yes No Is vessel equipped with operational smoke detectors?...yes No Verify that your Smoke and CO detectors are in proper working order. There are many areas such as swim platforms, cabin areas and on deck where CO can accumulate. For more information on Carbon Monoxide visit As part of this self survey, we strongly recommend that you also arrange for an annual Vessel Safety Checks. A Vessel Safety Check is a courtesy examination of your boat to verify the presence and condition of certain Safety Equipment required by State and the Federal regulations. The Vessel Examiner is a trained specialist and is a member of the United States Power Squadrons or the US Coast Guard Auxiliary. They will also make recommendations and discuss certain safety issues that will make you a safer boater. See for more information and a list of required equipment. MHY Copyright 2010 American Underwriting Managers Agency, Inc. Page 4 of 5

5 Navigational Equipment: Please list all electronic items on board for the safe operation or navigation of your boat: Item Make /Model Purchase Date Purchase Price Installed by VHF: GPS: Depth Finder: Radar: Auto Pilot: Photographs Required: The following areas must provided: Side Overview All Navigation Equipment; Engine Compartment; Stern/Transom Bilge; Overview; Helm Station Tender. Each Engine; Generator; Photographs can be 35mm or digital and must accompany this report. I attest that to the best of my knowledge and ability that the information provided is true and correct. I attest that I have read and understood the technical aspect of this request, examined the components and provided an accurate answer. This document is limited and is intended to be a alternative to a full Condition and Value survey. I realize the best way to ensure that my boat is fit for its intended purpose/usage is to hire a professional marine surveyor to assess the condition. Insured Date Insured Date Please return this document and the photographs to your agent. MHY Copyright 2010 American Underwriting Managers Agency, Inc. Page 5 of 5