SINGLE OR TWIN ENGINE?:

VESSEL PURCHASED NEW OR USED:

IF OWNER IS A CORPORATION,
LIST ALL OWNERS AND PERCENTAGE OF OWNERSHIP.

DOES OWNER REGULARLY OPERATE VESSEL?:

Submitting this form does not obligate the owner to purchase insurance, nor does it obligate Allied Security Insurance Agency LLC or an Insurance Company to accept the risk.

 It is agreed that this form shall be the basis of the contract should a policy be issued and authorizes the Company to conduct an investigative consumer report.  Please review this report before submitting to our office as false information may void your insurance.

When you have reviewed your application, please click on the “SUBMIT”  button and we will process your application as soon as possible.  We will acknowledge the receipt of your application by email to the address you provided in the application.

Should you have any questions while completing this application, please call us at 800-627-5733 or if it is after normal business hours, you may call Greg @ 985-981-4077

Thank you again for your interest in our facility.

WOOD

COMMENTS/SPECIAL INSTRUCTIONS:

VESSEL NAME:

VESSEL TYPE:

HOME PORT:

OFFICIAL NUMBER:

YEAR BUILT:

BY WHOM:

WHERE BUILT:

CONSTRUCTION:

STEEL

FIBERGLASS

LENGTH OVERALL:

BEAM:

DEPTH:

SINGLE

TWIN

ENGINE MODEL:

ENGINE YEAR BUILT:

ENGINE HORSEPOWER EACH:

WHAT WATERS NAVIGATED?:

NEW

USED

FROM WHOM?:

DATE PURCHASED:

PRICE PAID TO SELLER:

PRESENT DAY MARKET VALUE:

REGISTERED OWNER:

OWNER SSN:

CORPORATE INFO:

OWNERS AGE:

PHYSICAL ADDRESS OF OWNER:

OWNER PHONE NUMBER:

OWNER EMAIL:

YES

NO

NUMBER OF CREW:

NUMBER OF PASSENGERS:

FOR WHOM DOES VESSEL WORK?:

DESCRIBE WORK:

DESCRIBE ANY OTHER VESSELS OWNER OR OPERATED DURING PAST 5 YEARS:

DESCRIBE ANY LOSSES OR CLAIMS, INCLUDING THE AMOUNT OF LOSS EXPERIENCED DURING THE PAST 5 YEARS:

AMOUNT HULL INSURANCE REQUESTED:

AMOUNT OF PROTECTION & INDEMNITY (LIABILITY) REQUESTED:  REQUESTED REQUESTED:

NAME OF PRESENT OR LAST INSURER:

DATE POLICY EXPIRES:

CURRENT AGENT:

PLEASE PRINT THIS PAGE FOR YOUR RECORDS PRIOR TO PRESSING SUBMIT.

APPROVE. I have read, agreed to, and approve submission of this application