Commercial Marine Supplemental Application Form
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1COMMERCIAL MARINE SUPPLEMENTAL APPLICATION
PREMISES LIABILITY
Completion of this application does not constitute an agreement by the Company to bind insurance. The application
represents that the information provided here is accurate and a true basis upon which insurance may be considered.
If coverage is bound by the company, this document will become part of the policy.
Requested Effective Date: ________________
Producer Name/Address, Phone and Fax #:
Limit:
$300,000CSL
$500,000CSL
$1,000,000
1.) Applicant’s Business Name & Mailing Address:
2.) Premises Address- Give exact location of area you wish to insure, including name of marina, pier or slip number;
indicate the part occupied: ______________________________________________________________________________
What is the square footage of the Applicant’s occupied area? ________
Does this include a parking lot, docks, piers or buildings?
Yes
No- Explain: ____________________________
Include a diagram of the area
3.) What is the interest of the Named Insured in the premises? (check one):
Owner
Tenant
Other; Explain: _____________________________________________________________________________________
4.)
How long has applicant operated from this location? ____________
5.)
How long in this business? __________
6.)
List & describe the specific activities conducted by the applicant: ____________________________________________
7.)
Describe any special contractual agreements entered into by the applicant (ie, lease, contracts of carriage, towage
ect): _______________________________________________________________________________________________
***(ATTACH COPY OF ANY LEASE AGREEMENT- This is required)
8.)
List & Describe all prior losses or claims for this applicant within the past 5 years: ______________________________
_________________________________________________________________________________________________________
9.)
List & Describe all other business activities conducted on this premises, whether owned or non-owned: ___________
____________________________________________________________________________________________________
If owned, is there other insurance in force? Explain: ________________________________________________________
10.) Provide a detailed breakout of the estimated annual Gross Receipts for : Boat Rentals:________ Fueling: _________
Storage: _____________ Slip Rentals: ___________ Hauling/Launching: ___________ Boat/Motor Repairs: ____________
Retail Store: _________ Restaurant/Snack Bar: _________ Hotel/Campground: __________ Boat Sales/Service: ________
Other- Explain: ___________________________________________________________________________________________
11.) List names and address of all applicable Additional Interests: _______________________________________________
________________________________________________________________________________________________________
Insured’s Statement and Signature
This notice is given in compliance with the Federal Fair Credit Reporting Act (Public Law 91-508). I understand that as a part of the Company’s
underwriting procedures, a routine inquiry may be made which will provide applicable information concerning character, general reputation, personal
characteristics, mode of living and business practices. The statements made here and signed by the owner(s)/applicant represents the information
set forth as correct and a true basis on which insurance may be granted, but in no way binds the applicant to accept quotation or insurer to accept
risk.
Applicant’s Signature: ___________________________ Title: ______________ Date: ___________
Producer’s Signature: ____________________________
Date: ___________
WC5041(6/95)
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