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PORT RISK COVERAGE REQUEST

(Required to obtain or continue Port Risk Coverage)

OWNER_________________________________________________                 POLICY #  _____________________________

ADDRESS______________________________________________________________________________________________

CITY_________________________________________________________     STATE __________      ZIP_________________

BOAT’S NAME ______________________    LENGTH__________  YEAR _______

BUILDER  ___________________________BOAT TYPE/ MODEL ____________________________________

BOAT WILL NOT BE USED AND IS:    UNDER CONSTRUCTION                 BEING RESTORED

          AWAITING RESTORATION  OTHER  (EXPLAIN)  ____________________________________________

_______________________________________________________________________________________________________

WHERE IS BOAT LOCATED? (ADDRESS)___________________________________________________________________

DESCRIPTION OF BOAT’S STORAGE FACILITY ____________________________________________________________

SECURITY PROVISIONS AT FACILITY  ____________________________________________________________________

HOW OFTEN IS BOAT CHECKED?_________________________ BY WHOM?_____________________________________

BOAT IS:AFLOATASHORE

IF AFLOAT, DOES THE BOAT HAVE:        MANUAL BILGE PUMPS?       YES_______  NO______  HOW MANY?______

              AUTOMATIC BILGE PUMPS?  YES____ NO____   CAPACITY________   HOW MANY?_____

HOW IS THE BATTERY CHARGED? _______________________________________________________________________

IF AFLOAT, IS THE BOAT AT              DOCK            MOORING        

IF AT MOORING GIVE ANCHOR TYPE________________________ANCHOR WEIGHT  _____ CHAIN SIZE ______

RODE SIZE________WHEN WAS ENTIRE MOORING LAST INSPECTED? __________________________________

IF AFLOAT, ARE ALL THRU HULL VALVES CLOSED? _________ IF NOT, WHY?_________________________________                   

IF AFLOAT, ARE ALL OTHER HULL PENETRATIONS AND CONNECTING HOSES (EXHAUST, HEAD, COCKPIT DRAINS, INTAKE, ETC.) PROPERLY INSTALLED?________________  

IF NOT PLEASE DESCRIBE INSTALLATION_________________________________________________________________

BOAT IS BEING RESTORED AND IS NOW _________% COMPLETE.   ESTIMATED COMPLETION DATE IS __________

I HAVE  INVESTED $ ______________ FOR THE INITIAL ACQUISITION AND $______________ TOWARD THE RESTORATION.  I BELIEVE AT THIS POINT THE BOAT IS WORTH $ _______________.  I WISH TO INSURE THE BOAT FOR A VALUE OF $ ___________________.  BRIEFLY DESCRIBE REMAINING WORK TO BE DONE.  ________________

_________________________________________________________________________________________________________

PLEASE ENCLOSE CURRENT INTERIOR AND EXTERIOR PHOTOS.

PORT RISK COVERAGE FOR THE ABOVE DESCRIBED BOAT IS HEREBY REQUESTED.  THE UNDERSIGNED OWNER CERTIFIES THAT ALL OF THE INFORMATION PROVIDED ON THIS FORM IS TRUE AND CORRECT AND UNDERSTANDS THAT PORT RISK INSURANCE EXCLUDES ANY COVERAGE FOR NAVIGATION OR MOVEMENT OF THE BOAT VIA TOWING, ITS OWN POWER OR SAIL, TRAILER OR ANY OTHER MEANS WITHOUT PRIOR WRITTEN APPROVAL FROM HERITAGE MARINE INSURANCE.  

SIGNATURE_____________________________________________       DATE ________________         

                                        SIGNATURE OF OWNER

PO BOX 188, MYSTIC, CT  06355

800-959-3047

FAX 860-572-5919

HMIrev(12-02)

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