Applicant Details

Name / Company Name *

Address *

Date of Birth *

Nationality *

Contact Number *

E-mail Address *

Cover Required

Type of Cover *

Comprehensive including Third Party Liability Third Party Only

Crew Cover

Yes No

Vessel Details

Use of Vessel *

If Charter or Commercial Use — details (charter type & number of days annually)

Vessel Information

Vessel Name

Type / Class of Vessel *

Make and Model *

Hull Material

Overall Length (feet) *

Year of Manufacture

Vessel Value (GBP) *

Purchase Price & Date

Permanent Berth

Country of Registration

Engine(s) Details

	Make / Model	Year	HP	Serial Number	Fuel
Engine 1
Engine 2

Outboard Engine/s Value (GBP)

Maximum Design Speed (knots)

Navigational Waters

Navigational Waters / Areas *

Additional Cover

Racing Risks Extension (applicable to sailing yachts only)

Yes No

Liability for the Towing of Water Toys or Water Skiing

Yes No

General Questions

Qualifications & Experience *

Is the Vessel Currently Insured? If so, please provide the current insurer:

Current Premium

Expiry Date

Claims History

Additional Information

Declaration

I/We declare that the statements and particulars contained in this form are true and complete.

I/We will provide details of any alteration to this information as soon as possible prior to commencement of the period of insurance.

I/We agree that if any answers have been completed by any other person, such person shall for those purposes be regarded as my/our agent and acting on my/our behalf.

I/We agree to receive the insurance indication and all other correspondence by email, post, SMS and/or telephone.

I/We agree to the above declaration and confirm the information provided is true and complete.*

✓ Thank you — your enquiry has been submitted successfully. A member of our marine team will be in touch shortly.

Something went wrong. Please try again or contact us at marine@capurroinsurance.com