Witherspoon and Associates / CHARTER LAKES PASSENGER VESSEL INSURANCE APPLICATION

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2 Witherspoon and Associates / CHARTER LAKES PASSENGER VESSEL INSURANCE APPLICATION REGISTERED OWNER OR LEASEE NAME & ADDRESS DOING BUSINESS AS: PRODUCER 709 Blackhorse Pkwy., Franklin, TN ( Fax) HOME PHONE WORK PHONE FAX NUMBER ADDRESS DRIVERS LICENSE # DATE OF BIRTH OCCUPATION CURRENT INS. CARRIER EXP. DATE OF CURR. POL CURRENT PREMIUM HULL NAME OF VESSEL REG./DOC. NO. HULL I.D. NO. CRUISER/MOTORYACHT SAILBOAT FLATS SKIFF HOUSEBOAT DRIFT BOAT CENTER COSOLE TYPE OF VESSEL SPORT FISH PONTOON AIRBOAT FISHING TRAWLER CUSTOM BUILT YEAR LENGTH # OF DECKS VESSEL MANUFACTURER MODEL MATERIAL BEAM WEIGHT PURCHASE DATE PURCHASE PRICE WATERS NAVIGATED AND MAXIMUM MILEAGE OFFSHORE NEW REPL. COST DATE OF LAST SURVEY OPERATING PERIOD YEAR ROUND SEASONAL MOORING LOCATION WHEN IN SERVICE-MARINA, CITY, ZIP LAY-UP LOCATION WHEN NOT IN SERVICE-MARINA, CITY, ZIP MACHINERY MAX SPEED EQUIPMENT GAS DIESEL TYPE OF DRIVE IB IO JET DRIVE SURFACE DRIVE OB GPS SNIFFER LIFE RAFT TRAILER CREW INFORMATION GENERAL WHEN NOT IN USE VESSEL IS STORED ASHORE AFLOAT WARRANTED LAID UP PERIOD (OUT OF COMMISSION) FROM TO MANUFACTURER AND MODEL MANUFACATURE DATE OF ENGINE(S) NO. OF ENGINES H.P. EACH VHF SAT-NAV LP. GAS STOVE LORAN GENERATOR AUTO-PILOT SERIAL NO. SERIAL NO. YEAR MANUFACTURER SERIAL NO. DO YOU EMPLOY CREW RADAR SINGLE SIDE BAND BURGLAR ALARM ENGINE HOURS ENGINE HOURS MAX # OF CREW EMPLOYED AT ONE TIME (INCLUDE CAPTAIN & MATES) # YRS IN CHARTER BUSINESS # YRS BOATING EXP IS VESSEL OWNER OPERATED (IF NO, PLEASE PROVIDE OPERATOR INFO ON PAGE 2) DESCRIBE TYPICAL CHARTER IN DETAIL DESCRIBE HOW VESSEL IS USED BE SPECIFIC ON TYPE OF CHARTER AND AVERAGE LENGTH OF A TRIP DEPTH FINDER AUTOMATIC CO2 OR HALON EPIRB ARE YOU A LICENSED CAPTAIN # CHARTER DAYS PER YEAR DO YOU CHARTER OVERNIGHT YES (EXPLAIN) NO DO YOU SELL OR SERVE FOOD GROSS RECEIPTS FOOD DO PASSENGERS SWIM, SNORKEL OR SCUBA DO YOU SELL OR SERVE ALCOHOL DO YOU TOW PASSENGERS ON WATER SKIS OR WATER TOYS GROSS RECEIPTS ALCOHOL TOTAL ANNUAL PASSENGERS CARRIED MAX # PASSENGERS LICENSED FOR AVG # CARRIED PER CHARTER COVERAGE EFFECTIVE DATE LIABILITY LIMIT REQUESTED 100, , ,000 1,000,000 OTHER MEDICAL PAYMENTS UNINSURED BOATERS HAS INSURANCE BEEN CANCELLED OR REFUSED LOSS INFORMATION HULL, MACHINERY and EQUIPMENT VALUE (CURRENT MARKET VALUE) IF SO, PLEASE EXPLAIN DEDUCTIBLE 500 MINIMUM TRAILER VALUE PERSONAL EFFECTS/MISC. FISHING EQUIPMENT CAPTAIN/CREW COVERAGE REQUESTED LIST ALL MARINE INSURANCE CLAIMS YOU HAVE FILED IN THE LAST FIVE YEARS REGARDLESS OF VESSEL INVOLVED (INCLUDING BODILY INJURY TO PASSENGERS OR CREW). IF NO LOSSES INDICATE NONE DATE DETAILS OF LOSS OR CLAIM AMOUNT PAID/OUTSTANDING STATUS

3 CONTINUED ON NEXT PAGE OPERATOR INFORMATION (REQUIRED IF VESSEL IS OPERATED BY ANYONE OTHER THAN OWNER LISTED ON FIRST PAGE) # NAME DATE OF BIRTH DRIVERS LICENSE # & STATE YRS OPERATING COMMERCIAL VESSELS USCG LICENSED 1. # YRS LICENSED HAS ANY OPERATOR OF THIS VESSEL(S) BEEN INVOLVED IN A MARINE RELATED ACCIDENT IN THE PAST (3) YEARS NO YES (EXPLAIN) ARE MAINTENANCE AND OPERATION LOGS KEPT FOR THIS VESSEL NO YES (EXPLAIN) DATE OF LAST HAUL OUT AND WORK COMPLETED IS THERE ANY PRE-EXISTING DAMAGE TO THIS VESSEL NO YES (EXPLAIN) DATE OF LAST HAUL OUT AND WORK COMPLETED DOCK LIABILITY ARE YOU RESPONSIBLE FOR ANY PROPERTY ADJACENT TO DOCKING LOCATIONS NO YES (EXPLAIN) DO YOU SELL ANY PRODUCT ON LAND NO YES (EXPLAIN) IS THERE A PARKING LOT THAT LIABILITY COVERAGE IS BEING REQUESTED FOR NO YES (EXPLAIN) CORPORATE OWNERSHIP AND CORPORATE OFFICERS NAME PERCENTAGE OWNERSHIP TITLE DO YOU OPERATE VESSEL USCG LICENSED ADDITIONAL INTERESTS (PLEASE LIST NAME, ADDRESS AND INTEREST OF ALL ADDITIONAL INSUREDS, CERTIFICATE HOLDERS AND LOSS PAYEES) NAME ADDRESS: STREET, CITY, ZIP INTEREST COMMENTS (PLEASE USE TO EXPLAIN ANY YES RESPONSES WHERE AN EXPLANATION IS REQUESTED) IT IS UNLAWFUL TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT, FINES, DENIAL OF INSURANCE, AND CIVIL DAMAGES. I UNDERSTAND THAT THIS APPLICATION BECOMES A PART OF THE INSURANCE POLICY. l. I agree that the Company may investigate and secure motor vehicle records for persons listed in this application. 2. I declare that the statements contained herein and in the attached Watercraft Application are true to the best of my knowledge and belief. The selections indicated herein and in the attached Watercraft Application accurately reflect the limits, Coverages and deductibles I desire. 3. In connection with this application for insurance, we may review your credit report, obtain or use a credit-based insurance score based on information contained in that credit report. We may use a third party in connection with the development of your insurance score. EFFECTIVE DATE OF COVERAGE DATED APPLICANT SIGNATURE DATED PRODUCER SIGNATURE My (the producer) signature verifies that all of the information on this application has been obtained by me from the applicant and that I have no reason or basis to believe that the information is anything but truthful.

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