SKIPPERED CHARTER VESSEL APPLICATION 1. Applicants Name and Mailing Address:
2. Number of years in business: 3. Additional related experience a/o certification:
4. Type of charters:
Sightseeing Whale watching Instruction
5. a. Annual Gross Receipts:
Dive Water skiing Other (describe)
Sport Fishing Water sports
b. Number of Charters per year:
6. Indicate typical duration of charter (ie day only or overnighters): 7. Any waterskiing or water toys (describe toys):
8. a. b. c. d.
Yes Yes Yes Yes
No No No No
Are food and beverages provided: Any alcohol served on board: Is food and beverage provided by a third party (ie caterer) Is this third party required to provide proof of liability insurance?
9. Number of crew on board any one charter: 10. Are crew covered by Worker’s Compensation: 11. Maximum number of passengers any one charter:
12. Describe passenger orientation and safety procedures given to passengers prior to boarding:
13. Are passengers required to wear life jackets at all times once onboard: 14. Where is the vessel moored:
15. What waters does the vessel operate in:
16. Describe area vessel trailered in if applicable: 17. a. Usual Charter Season: b. Lay up period (if applicable): c. If laid up please describe lay up method (ashore, afloat etc…) and security details in full:
18. a. Have you had any claims or losses in the past 5 years? If so, please provide details: b. Have you been involved in any major losses at any time? If so, please provide details:
Please complete the attached Owner’s/Skipper’s Questionnaire for all owners and/or operators.
20) a. Do any of the skippers have first aid training? b. If yes please describe:
22.a. Do you have a commercial general liability policy in force: Yes b. Insurer: c. Policy No.: VESSEL DETAILS (if more than one vessel please attach separate page with details) Vessel Name Type/Class of Year Built Length Hull Colour & Vessel Material
21. a. Prior insurance company: c. Expiry Date: d. Ever been cancelled by an Insurance Company: e. If yes please advise why:
b. Policy No.:
Engine Type (ie in/outboard..)
H.P. of Each Engine
Serial No. of Engines
Date Vessel Purchased
Current Market Value
Insurance Coverages Requested Insured Value/Limit Deductible Of Liability
Hull License Number
1. Hull and Machinery* 2. Dinghy and dinghy motor* 3. Trailer* 4. Boathouse* 5. Protection & Indemnity *(Show total values all vessels above but indicate separate values with vessel descriptions) Agent’s Address:
Agent / signature:
Applicant’s signature: By signing this application the applicant declares that all information contained herein is accurate and true to his/her knowledge and understands that non-disclosure or misrepresentation of a material fact may entitle Underwriters to void the insurance. By signing this application the applicant also grants permission for the Insurer, Broker, or their representatives to verify that the above information contained in this application is true.
SKIPPERED CHARTER SUPPLEMENTARY SAFETY QUESTIONNAIRE Applicant:
PLEASE ANSWER ALL OF THE FOLLOWING QUESTIONS:
1. Do you have a written safety and procedure manual? If yes, please provide a copy. 2. Do you have a procedure checklist to be followed by all skippers & staff? If yes, please attach a copy. 3. Do you keep a log or journal to record any and all incidents?
4. a. Do you conduct pre-activity briefing with charter passengers? b. Describe in detail:
5. What is the maximum number of passengers allowed per vessel?
6. Are there any age restrictions for charter passengers?
7. a. Are life jackets provided to all passengers? b. Are passengers required to wear lifejackets at all times whilst aboard vessel? 8. a. Are all vessels equipped with communication devices? b. If yes please describe:
APPLICANT’S SIGNATURE: By signing this questionnaire the applicant declares that all information contained herein is accurate and true to his/her knowledge and understands that non-disclosure or misrepresentation of a material fact may entitle Underwriters to void the insurance. By signing this application the applicant also grants permission for the Insurer, broker or their representatives to verify that the above information contained in this application is true.