Yacht Insurance Application
Directions: Please complete this form and click the SEND button. A representative of Olson, Inc. will follow up with you within 24 hours to confirm this application and answer any questions you may have. If you require immediate assistance, please contact Olson, Inc. at 410-923-7100.   
Primary Owner / Name Insured  
Is Vessel To Be Titled In a Corporate Name? Yes No  
If Yes, Is This For tax Purposes Only? Yes No  
Corporate Name (only eligible for tax purposes only)
Policy To Be Insured In The Name Of * (first middle last)
Address * (street, apt.#, city, state, zip) Street Address State Zip
Telephone Number(s) * (home) (work) (cell) (fax) home work cell fax
Driver's License Information (number) (state) State
Date of Birth
Social Security Number
Occupation
Experience # of Years?
Length / Type Vessel
Boating Safety Courses Taken Coast Guard Course Coast Guard Academy
Coast Guard Auxiliary Captain's License
Power Squadron Other (explain in comments)
Comments

Mooring and Storage Location(s) Primary Location
Owner Residence Public Storage
Marina Other (explain in comments
Address (street address, city, state, zip)
Marine / Berthing Location Name (if applicable)
Indicate Type of Security
County

Yacht Description Usage Private Pleasure    /     Liveaboard Yes No
Year Of Vessel *
Length Of Vessel *
Name Of Vessel *
Make Of Vessel *
Model Of Vessel *
Hull Type Power-Mono Hull Power-Multi Hull Sail-Mono Hull Sail-Multi Hull
Hull Material * Fiberglass Wood Steel
Fiberglass Over Steel Aluminum
Other (explain in comments Comments
Propulsion/Fuel * Gas Diesel Electric Gas w CO2 None
   
HIN
DOC/REG Number
Max Speed
Weight
Where Did You Purchase This Vessel
Purchase Price
Hull Value
Liability Limit
Lien Holder
Lien Holder Address
Balance of Note Remaining
Date of Recent Survey
Any Existing Damage Yes No Explain
Is Vessel Used To Race? Yes No Explain Give Percentage Raced %
Safety Equipment Central Station Monitoring System Alarm System
Other (explain in comments)
Navigation Warranty
 

Engines and Motor(s) Detail  
Motor Year
Manufacturer
Serial Number
Horsepower
(per engine)
Value
Trolling Motor?

Tender(s)
Year
Length
Mfr
VIN
Motor Year
Motor Mfr
Motor Serial #
HP
Total Value (incl motor)
 

Trailer
Year
Manufacturer
VIN
Value

Lay-up Information
Lay-Up Period Dates From  To
Address / Location (street, city, state , zip) Ashore Afloat
   

Additional Owner / Operators Information  
Name
Date of Birth
Drivers License # State
SS #
Person Is Owner or Operator? Owner / Operator
Boat Safety Courses? (list all)
Experience (# years, vessel type, length)

Accidents and Losses
Accident or Loss? Accident Loss           Description
Accident or Loss? Accident Loss           Description
Is Vessel Insured Now Yes No
   

* REQUIRED FIELDS

Olson, Inc.   882 Annapolis Road, PO Box 187 , Gambrills, MD 21054
Email: inquiry@insurewitholson.com    Telephone 410-923-7100    1-866-34-OLSON (6-5766)