London Marine Insurance Services Limited Suite 312,1 Alie Street, London, E1 8DE, United Kingdom

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1 London Marine Insurance Services Limited Suite 312,1 Alie Street, London, E1 8DE, United Kingdom Tel: Fax: MARINE YACHT HULL & MACHINERY INSURANCE PROPOSAL FORM Insured s Name / Address : Vessel : Covers Required : Hull & Machinery War Risks Tender Personal Property Medical Expenses Uninsured Boaters Protection & Indemnity Crew Liability Passenger Liability Pollution Liability Electronics Towing Trailer Sum Insured Navigation details : Personal Details Have you ever had a CCJ / Debt Judgement or been made bankrupt during the last five years? Have you ever been refused insurance, had special terms imposed or had a policy cancelled? : Page 1 of 5

2 Have you any current convictions, police cautions or pending prosecutions (other than motoring convictions)? Have you 3 years experience and no claims in the last 5 years If NO please provide additional details : Do you possess a recognised yachting qualification Vessel Details Is the vessel used for Private and Pleasure use or Charter Hire Is the vessel powered by Motor or Sail What is the Vessel Length Who was the Builder In what year was the vessel built What is the Maximum Designed Speed What are the Engines (number and type) Additional details: Does the Vessel have any Surface Drives What is the hull construction type Does the vessel have automatic fire extinguishers What is the Class The Vessel Flag The mooring Country If moored in USA, in which State If moored in Florida, in which County Where is it normally moored Page 2 of 5

3 In what Berth Number How many Crew do you have Professional crew Is the vessel diesel powered only (sailing yachts) Is there any racing / rally use Is the vessel a catamaran Is the vessel a trimaran / ferro Navigation Details Do you navigate in Inland waters only If NO please provide additional details : Are you intending to navigate around New Zealand / Australia Are you intending to navigate around the Mediterranean Sea / Europe Are you intending to navigate around the West Coast of USA / Mexico Are you intending to navigate around North of Cabo San Lucas from 15/06 to 15/10 Are you intending to navigate around Chesapeake Bay and North from 01/06 to 01/11 Are you intending to navigate around Cuba / Columbia / Haiti / Venezuela Are you navigating single handedly Will there be any Trans Pacific navigation (one Will there be any Trans Pacific navigation Page 3 of 5

4 Will there be any Trans Atlantic navigation (one Will there be any Trans Atlantic navigation Will there be any Indian Ocean navigation (one Will there be any Indian Ocean navigation Will there be any Hawaii navigation (one Will there be any Hawaii navigation Will there be any Bermuda navigation (one Will there be any Bermuda navigation Will there be any Panama transit (one Will there be any Panama transit : Cover Details Law & Practice Jurisdiction Will you be Laying-up the vessel English / USA Do you wish to cover for lightning strikes Page 4 of 5

5 Do you require windstorm cover in "the Box" Any claims history in the last 5 years If YES, was this a No fault claim Please provide additional details :: Additional information : Signed Name Date Page 5 of 5

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