Proposal Form

LLP 1339 - Jul 14 - Commercial

Insurance for Yachts & Motorboats

Please complete, sign and return together with the attachments to: Yacht Practice of Lockton Companies LLP The St Botolph Building 138 Houndsditch London EC3A 7AG Tel: +44 (0)20 7933 0132 Email: yachtinsurance@uk.lockton.com   Website: www.lockton.com/yachtinsurance

Introduction

As a commercial customer you have a duty to disclose all material facts or changes in material facts already disclosed that might influence an insurer in making a decision whether to accept your risk and the terms and conditions and premium to apply.  Examples of the information that should be disclosed to underwriters is detailed below but the list is not exhaustive:

• Ownership/Registration/Flag • Market Value • Trading/areas of navigation • Use • Crew Numbers and Nationalities • Claims History • Changes to Professional Crew • Home Berth • Registration • Number of Crew • Trading Requirements. Your duty of disclosure arises prior to inception and during the policy period, if changes occur during the period of insurance you must advise us, if you are unsure whether a fact or change is material you should disclose it.    Failure to provide all “material facts” and/or notify all “material changes” may cause the contract of insurance to be void and may result in Insurers refusing to handle or settle any claims.

Please ensure  that all questions in this proposal form are answered completely and truthfully and provide any further information that you believe to be relevant on separate sheets of paper.

Lockton Companies LLP Authorised and regulated by the Financial Conduct Authority

A Lloyd's Broker,LLP 1339 - Jul 14

Additional information should be provided on separate sheets (ideally on your headed notepaper), clearly identifiable as forming part of the proposal form.

A. Details of Proposer

Name of Insured:1.

Address:

City:

Country:

County: Post Code:

Tel No:Email:

2.

3. Occupation:

Name of Beneficial Owner (if not the insured named above):

Nationality of Beneficial Owner:

4.

Experience & Qualifications:5.

a) Do you have a Professional Skipper/Crew6. Yes No

If 'Yes', please provide CV's for the professional crew on a separate sheet of headed notepaper.

Have you had any accidents/claims/losses in connection with any vessel you have sailed/owned/under your control in the last 5 years

7. Yes No

If 'Yes', please provide details, including dates and amounts paid:

Have you ever been refused insurance? 8. Yes No

If 'Yes', please provide details:

Have you or any person you have allowed or may allow to use your craft, ever been charged with or convicted of any offence involving dishonesty of any kind, e.g. fraud, arson, robbery, smuggling, theft or handling stolen goods?

9. Yes No

If 'Yes', please provide details:

Previous Insurers:10.

LLP 1339 - Jul 14

Date of Birth:

b) No of Crew:

B. Details of Vessel

Date built:

Name:

Builders:

1.

Mast Manufacturer:Material of Mast:

Classification: Material of Hull:

Beam:Length: GRT:Draft: Maximum designed speed:

Type/Model:

Flag:Port of Registry: GRT:IMO No:

Type of Hull: CatamaranMono

Has the vessel been professionally surveyed in the last three years ?: 3. Yes No

If 'Yes', please provide surveyor's name and a copy of survey:

2.

Registration of the Vessel: Commercial or Private? 4.

Price paid:Date purchased:5.

Is the vessel subject to finance/mortgage? 6. Yes No

If 'Yes', please state amount of loan and name of finance company:

toPeriod of Insurance:7.

C. Value to be insured

Currency:1.

Vessel:2.

Tenders/Outboard motors:3.

Personal Effects*4.

* Personal Effects are defined as items that would not be sold with the vessel

Sum to be insured:5.

6. Please list any other specific items within the vessel value:

Description Value Description Value

5. If the vessel has been offered or advertised for sale during the past 12 months, please confirm the advertised sale price:

LLP 1339 - Jul 14

Construction of the Rigging:

D. Engine/Machinery Details

H.P. (total):Year built:

1.

2. No of engines:

Other Jet:Stern Drive:Inboard: (please specify):Outboard: Surface-drive:

Type:3.

CODOG:CODAG:Diesel:Petrol:

Fuel:4.

Other Foam:Water:Manual: (please specify):Automatic: CO2:

Fire Extinguishers:5.

E. Navigation & Use

Navigation Limits:1.

Other

Private pleasure:

(please specify):

Use:2.

Skipper charter: If day charter, please state no of passengers:Bareboat charter:

Other Pile:Swing:Marina pontoon: (please specify):Fore & aft

Moorings;3.

Marina stern to:

In-commission period:Mooring location:4. Location of lay-up:

Limit for Waterskiers Liability:Third Party Liability limit required:5.

Does vessel have a Protection and Indemnity coverage in place with a P&I Insurer?6. Yes No

If 'Yes', please state name of P&I Insurers and coverage in place.

Will the vessel be used for racing?7. Yes No

If 'Yes', please answer the following:

Replacement Value of Mast, Spars, Sails and Rigging:

Off-shore:Club:Type of Racing:8.

NB: Payments made by UnderwritersAny amounts due from Underwriters will be paid to the insured only as named in the certificate of insurance and it is essential that the insured has a bank account in the same name. Payments to Third Parties will be paid directly to the Third Party on behalf of the Named Insured, or as otherwise agreed.

LLP 1339 - Jul 14

Engine Serial No(s):

Make and model of engine(s):

Data ProtectionBy signing this proposal form you consent to Lockton Companies LLP using the information we may hold about you for the purpose of providing insurance and handling claims, if any, and to process sensitive personal data about you where this is necessary (for example criminal convictions). This may mean we have to give some details to third parties involved in providing insurance cover. These may include insurance carriers, third-party claims adjusters, fraud detection and prevention services, reinsurance companies and insurance regulatory authorities. In the course of performing our obligation to you, this information may be disclosed to agents and service providers appointed by us and insurers (which includes their re-insurers, legal advisers, loss adjustors or agents). Where such sensitive personal information relates to anyone other than you, you must obtain the explicit consent of the person to whom the information relates both to the disclosure of such information to us and its use by us as set out above. The information provided will be treated in confidence and, where appropriate, in compliance with the relevant Data Protection legislation. You have the right to apply for a copy of your information (for which we may charge a small fee) and to have any inaccuracies corrected. From time to time, we may disclose personal information (other than sensitive personal data) to other Lockton Companies. We or they may use that information to advise you of our services which may be of interest to you.

If you would prefer not to receive information, please tick this box

Print Name: Signature:

Date:

DeclarationIt is essential that every policyholder when seeking a new insurance cover or renewing an existing policy reveals to insurers any material facts or information (including any material circumstance or change in circumstances) which might influence the insurer in deciding whether or not to accept the risk. The material facts will also affect the terms or premiums to be charged. Failure to disclose a material fact may well render the insurance voidable from inception and enable insurers to repudiate liability. In practice, you should notify any changes in material facts or circumstances as soon as they arise. If you have any doubts as to what constitutes a material fact or circumstance, please do not hesitate to seek our advice. I/We declare that the above statements and particulars are true, full enquiry having been made, and I/We have not omitted, suppressed or mis-stated any material facts which may be relevant to insurer's consideration of this proposal form and undertake to inform the Insurer of any change to any material fact that occurs prior to the point at which the insurance contract has been agreed and throughout the insurance period.

Please note, if you wish to submit your form via email, an indication of terms and conditions may be provided on the basis of this proposal questionnaire. An original signature is required before a contract of insurance can be made. Encrypted signatures are not acceptable.

Signing this form does not bind the Practice to complete the insurance. We recommend that you keep a record of all information supplied to us, including copies of letters and this proposal form, for the purpose of entering into this contract.

Lockton Companies LLP Authorised and regulated by the Financial Conduct Authority

A Lloyd's Broker,LLP 1339 - Jul 14