| SECTION 1- THE PROPOSER |
|
Name
of Proposer |
|
Postal
Address |
|
Phone |
|
Fax |
|
Email |
|
Country |
|
Occupation |
|
Date
of Birth
(or if company, date established) |
|
Have
you, or any person who will take charge of the vessel, or any
other person with a financial interest in the vessel: |
a)
Ever had any insurances refused or cancelled? |
No
Yes |
| If
Yes, please supply details |
|
b)
Suffered any accidents or losses in the last 5 years? |
No
Yes |
| If
Yes, please supply details |
|
c)
Been charged or convicted of any offence in the last 5 years
? |
No
Yes |
| If
Yes, please supply details |
|
SECTION 2 - HULL & ENGINES |
|
| Vessel Name |
|
| No. of Engines |
|
| Country of Registration |
|
| Make / Model |
|
| Reg.No |
|
| Serial No(s) |
|
| Date of Purchase |
|
Type of Engine
(Inboard, outboard, jet, sterndrive? Other?) |
|
| Purchase Price |
|
| Turbo |
No
Yes |
| Date Last Surveyed |
|
| Power (HP) |
|
| Power or Sail |
|
| Cruising Speed (knts.) |
|
| Top speed (knts) |
|
| Year of Construction |
|
| Fuel Capacity (litres) |
|
| Construction Material |
|
| Fuel |
Diesel
Gasoline |
| Length (ft.) |
|
| Beam (ft.) |
|
| Draft (ft.) |
|
| If power boat, is vessel
fitted with stabilizers? |
No
Yes |
SECTION 3 – SAILS & RIGGING |
|
| Type of Rigging (e.g.:
sloop) |
|
Rigging
Wire, rod? Other? No. of spreaders? |
|
Type of Mainmast
Masthead? Fractional? Construction material? |
|
| Please list all sails
carried onboard |
|
| Is vessel fitted with
centre-board or lifting keel? |
No
Yes |
SECTION 4 – EQUIPMENT |
|
Please
indicate which of items of equipment are fitted or carried aboard
and give details where requested: |
| VHF |
No
Yes |
| Depth Sounder |
No
Yes |
| SSB |
No
Yes |
| Immersat |
No
Yes |
| Auto Pilot |
No
Yes |
| Compasses |
No
Yes |
| GPS |
No
Yes |
| Radar Reflector |
No
Yes |
| Emergency Positioning
Beacon |
No
Yes |
| First Aid Kit |
No
Yes |
| Lifejackets (no.) |
|
| Safety Harnesses (no.)
|
|
| Lifebuoys (no.) |
|
| Smoke/Heat Detectors (no.)
|
|
| Flares (Type, No &
Expiry Date) |
|
| Liferaft (Type, Capacity
& Expiry Date) |
|
| Fire Extinguishers (No.,
Auto/Manual, Expiry Date) |
|
| Tender / Outboard (Details) |
|
| Other (details) |
|
SECTION
5 – COASTAL OPERATION (within 100 nautical miles of Thai
Coast) |
Name
of person(s) who will Skipper |
Age |
No.
of Years |
Qualifications/Complete
Courses |
|
|
|
|
|
|
|
|
|
|
|
|
| Where is vessel normally
based? |
|
| Is this: |
Marina Berth
Fixed Mooring
At Anchor |
Vessel’s Main Navigation
Area
(eg. West Coast Thailand, Gulf of Thailand) |
|
| SECTION 6 –
OFFSHORE OPERATION (outside Thailand and/or more than 100 nautical
miles off Thai Coast ) |
Name |
Age |
Position
(eg. Crew) |
Years Experience |
Qualifications/Complete
Courses |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
List
previous offshore passenger or
ocean crossing undertaken by |
|
|
|
| Please give details
of intended voyages: |
|
Navigation
Area Country, Islands |
Est. Voyages
per year |
Max.days /nights
at sea any one voyage |
Proposed Mooring
at Destination |
|
|
|
|
|
|
|
|
|
|
|
|
SECTION
7- RACING |
|
| If Club Racing, state
name of Yacht Club |
|
| Specified Races
/ Regattas – Please give details |
|
Name
of Race/Regattas |
Location |
Proposed Dates |
Max.Length (NM)
any leg |
|
|
|
|
|
|
|
|
|
|
|
|
| Please give
details or previous racing undertaken by |
|
|
|
| SECTION 8 –
COMMERCIAL USE |
|
| Nature Of Use |
Bareboat Charter
Skippered Charter
Day Excursion |
| Other (details) |
|
| Do you prepare or supply
Food & Drink? |
No
Yes |
Certified Sailing /
Dive Instructors
|
|
| Certificated First Aid
Medic |
|
| Other (no. & details) |
|
| For Any one Voyage: Maximum
No. of Paying Passengers |
|
| Maximum No. of Days/ Nights
at sea |
|
| SECTION 9 –
LAY-UP |
|
| Lay-Up Location |
|
| Is this |
Ashore
Afloat |
| At |
Marina
Fixed Mooring
Anchor |
| Lay-Up Months |
|
| SECTION 10 –INSURANCE
COVER |
|
| Do you require cover to
include |
|
| Inland Transit Insurance
(For Trailer Sailers) |
No
Yes |
| Water Skies Liability
Insurance |
No
Yes |
| Food & Drink Liability
Insurance |
No
Yes |
Compulsory Passenger Insurance
(Required for Commercially Used Vessels only) |
No
Yes |
| |
|
Please
read the noted accompanying this Application Form before selecting
the policy currency
and entering the levels of coverage required in the box below. |
| CURRENCY |
Thai Baht
US$ (United States Dollars) |
| COVERAGE SUM TO
BE INSURED |
|
| 1) VESSEL COVER |
|
| a) Hull |
|
| b) Engines |
|
| c) Masts, Spars, Ringing,
Sails |
|
| d) Equipment |
|
| e) Tender & Outboard
|
|
| f) Trailer |
|
| 2) THIRD PARTY LIABILITY
|
|
| 3) DEATH & DISABILITY
BENEFIT |
|
| a) Limit Any One Person
|
|
| b) Limit for Policy Period
|
|
| 4) PERSONAL EFFECTS |
|
| 5) COMPULSORY PASSENGER
INSURANCE QBE will automatically set the sum insured according
to the current statutory limits |
| |
|
SECTION
11- DECLARATION
The Information and answers provided by me / us in this Application
are true and correct and will be relied upon by the Insurer
in deciding whether to provide insurance cover and if so upon
what terms.
|
| Signature (Name) |
|
| Date |
|
| |
|
|