Application Form

Moored Boat Insurance

Agent or Boat Dealer (if applicable)

Date cover to start from *

The Insured

First Name *

Last Name *

Email Address *

Phone *

Address *

City *

Postcode *

Country *

Do you prefer correspondence to be via email or mail?EmailMail

Finance company (or other interested party)

How did you hear about us? *

Which advertisement?

Broker Name

Boat Dealer Name

Details

Do you need to add further people to this application?Yes

Please provide First & Last Name on separate lines

Vessel to Be Covered by This Policy

Vessel is the hull, fixtures and fittings.

Vessel Type *YachtLaunch

Make & Model *

Construction *

Please describe the construction *

Vessel Name

Year Built *

How much was the vessel purchased for? *

NZD

When was the vessel purchased? *

Length of Vessel (in Metres) *

Engines

Engine #1

Type and Manufacturer *

Year of Manufacture *

Horsepower *

Serial Number

Fuel Type *

Please describe the fuel type *

Installed Professionally *YesNo

Mounting *InboardOutboard

Add another engine?Yes

Engine #2

Type and Manufacturer *

Year of Manufacture *

Horsepower *

Serial Number *

Fuel Type *

Installed Professionally *YesNo

Mounting *InboardOutboard

Amounts to Be Insured

Hull, superstructure, fittings and inboard machinery, masts, spars, sail, rigging, furniture and other equipment normally used on board the vessel

$ (GST Inclusive) *

NZD

Including fuel, food and consumables - gear and equipment normally sold with the boat.

Dinghy or tender *

NZD

Including outboard motors up to 25 hp capable of being carried on deck or on davits on your vessel, or that is towed behind your vessel.

Other Property Insured

Do you have and want to insure other property with this vessel? *YesNo

Gear and equipment left permanently on board the vessel but which would not normally be sold with it, including life jackets, wet weather gear, flares, tools, spare parts, bedclothes, foodstuffs, cooking utensils, handheld VHFs/GPSs and other handheld electronic equipment.

Description of other items

Other items *

NZD

Personal effects, fishing gear, handheld electronic equipment up to $1,000 any one item (provided not otherwise insured) covered under vessel's gear.

Total Sum Insured GST inclusive (If applicable: Vessel, Dingy or Tender, Other Property)

$including GST

Legal Liabilities to Third Parties

Limit of indemnity:
$10,000,000 including GST

Mooring

Type *MarinaPileWharfSwing

Location *

Lifted from the water and inspected at least once every 2 years, or, in accordance with local Harbour Authority (or appropriate Authority) requirements *YesNo

Is the Vessel a liveaboard *YesNo

Meets minimum port authority requirements for vessel size *YesNo

Date last lifted *

Size of block, etc.

Vessel Details

Number of fire extinguishers *

Description of security alarm system

Will this Vessel be used for racing? *YesNo

Is this Vessel used solely for private pleasure? *YesNo

Number of Bilge Pumps

Manual

Automatic

Are all underwater through-hull fittings equipped with gate valves / seacocks? *YesNo

Have all seacocks, valves and self-drainers been inspected and in good order? *YesNo

Is the gas stove installed in accordance with NZS 5428 (i.e: is the bottle on deck or in a cockpit locker vented overboard and lined with approved materials)? *YesNoNot Applicable

Are the fuel tanks all externally vented? *YesNoNot Applicable

Is the engine fitted with an audible pressure/temperature alarm system? *YesNoNot Applicable

Please upload at least 1 photo of the vessel

Max. file size: 5 MB. Max # of files: 5

Alternatively, email your photos to insurance@nautical.co.nz

Operators

Usual Operator First Name *

Usual Operator Last Name *

Usual operator's birthdate *

Usual operators experience with moored vessels

Usual operator's formal marine qualifications

Have you or any other person who may operate the vessel ever had an accident or loss, or made a claim on any insurer?YesNo

Please provide full details

Have you or any other person who may operate the vessel ever had any convictions or committed a criminal offence?YesNo

Please provide full details

Have you or any other person who may operate the vessel ever had insurance cancelled or declined by any insurance company?YesNo

Please provide full details

Your Duty of Disclosure

When applying for insurance, you have a legal duty of disclosure to the insurer — to truthfully disclose all information that is relevant and/or material to the insurer, so as to enable it to decide whether to provide this insurance, and (if so) on what terms. You have this duty every time your policy renews and whenever you make changes to this policy.

If you breach this duty, then the insurer may elect to void your policy from inception or the last renewal date. This means that the policy will be treated as if it never existed

The duty to disclose relevant or material information is not limited to the questions listed in the proposal (if a proposal form is completed). Please ask us if you are not sure whether you need to disclose information.

Pursuant to the Privacy Act 1993

The following is brought to your attention:

This proposal collects personal information about you;
The information is collected to evaluate the insurance you seek;
The intended recipients of the information are Nautical Insurance and Vero Insurance;
The information is being collected and held by Nautical Insurance and Vero Insurance;
The collection of this information is required pursuant to the common law duty to disclose all material facts relevant to the insurance sought, and is mandatory;
The failure to provide this information may result in your application for insurance being declined or your insurance being void from the beginning;
You have rights of access to and correction of this information, subject to the provisions of the Privacy Act 1993.

I/we thereby warrant that no insurance company has refused or cancelled insurance, that the vessel is well found and in every respect seaworthy, and that the above statements and particulars are true.

I/we agree that the proposal and declaration shall be the basis of the contract.

Insurance Charges and Fees

By entering this contract of insurance, you agree to the following:

we may include a fee in the insurance charge;
we shall be entitled to charge you an additional administration fee for any alteration or adjustment to the policy that requires the production of further materials in relation to your cover;
in the event of cancellation of the policy, we are entitled to retain our remuneration including fees, commissions and brokerage paid by the insurer.

Insurer Financial Strength Rating

Vero Insurance New Zealand Limited has been given an AA- financial strength rating by Standard and Poor’s. The rating outlook is Stable.

The rating scale is available from the Vero Insurance website.

Privacy Act and the Insurance Claims Register

The Insurance Claims Register (ICR) is a database of insurance claims to which participant insurers have access. The purpose of the ICR is to prevent insurance fraud. The ICR is operated by Insurance Claims Register (ICR Ltd), PO Box 474, Wellington 6140.

This policy is issued to you on the condition that you authorise the insurer to place any claims made against this policy on the database of ICR Ltd, where they will be retained and be available for other insurance companies to inspect. You authorise the insurer to obtain from ICR Ltd personal information about you that is (in their view) relevant to this policy or any claims against it.

You have certain rights of access to and correction of this information subject to provisions of the Privacy Act 1993.

Declaration

Please read & agree.

By completing and submitting this proposal form,
I/we declared that to the best of my/our knowledge and belief these particulars are true, complete and correct. Subject to any right I/we have under the Clean Slate Act, I/we have not withheld any information or any other material fact likely to affect the provision of cover by Nautical / Vero Marine Limited.

I/We declare that:

Subject to any right I/we have under the Clean Slate Act, the information given is in every respect correct and complete and all material information, including details of previous losses/claims, has been disclosed to Nautical/Vero Marine.
I/we undertake to exercise all ordinary and reasonable precautions for the safety of the boat and I/we warrant that the boat is well found and in every respect seaworthy.
This application shall be the basis of the contract between Nautical/Vero Marine and myself/ourselves; and I am/we are willing to accept cover subject to Nautical/Vero Marine’s policy terms, conditions, exclusions and any special terms they may require.
The figures shown represent the current market value on the New Zealand market, or if less than 3 years old, the replacement value.
I/We are fully authorised to complete and sign this application on behalf of the person(s) named in the proposal.

I/We authorise:

Nautical/Vero Marine to give and obtain from other insurance companies, insurance brokers, the Insurance Claims Register Ltd or any other party any information relating to this or any other insurance held or previously held by me/us and any claim(s) made by me/us.

I/We undertake to inform Nautical/Vero Marine immediately of any material events or changes in circumstances which occur after the commencement of this policy and whenever the contract is varied or renewed. This insurance will not be in force until this proposal has been accepted by Nautical/Vero Marine

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