RENEWAL QUESTIONNAIRE

Previous Declaration Number  ____________________

Name of Insured (as it appears on policy) ___________________________________

1)                   Do you require any changes in coverage limits?  Below are your current coverages, please indicate changes required by filling in the next column.

CURRENT COVERAGE                REVISED COVERAGE

HULL VALUE:                                      ___________________                ____________________

HULL DEDUCTIBLE:                      ___________________                _____________________

LIABILITY:                                           ___________________                _____________________

MEDICAL PAYMENTS:                        ___________________                _____________________

PERSONAL EFFECTS:                              ___________________                _____________________

DINGHY/TENDER:                            ___________________                _____________________

OTHER (PLEASE SPECIFY)                 ___________________                _____________________

2)                   Have you added or deleted any navigational or safety equipment this year?  If so please advise us of these items.

_____________________________________________________________________

_____________________________________________________________________

3)                   Are there any new crew members/operators on your vessel?  If so, please advise age, experience and details of licences held &/or boating courses taken.  (If you need more room, please use the back of this page.)

___________________________________________________________________________

4)             Will your vessel be your full-time residence during the next policy period?  Please circle as appropriate:                          YES                OR                NO

5)             Please advise date of last survey ____________________________________

                IN                /                OUT                of water?    (Circle as appropriate)

6)                   Please give details of any further changes, e.g. Navigational limits

In order that we may make the required amendments to your renewal policy, we must have your signature giving us permission to do so.

Any misrepresentation in this application for renewal of insurance will render insurance coverage null and void from inception.  Please therefore check to make sure that all questions have been fully answered and that all facts material to your insurance have been disclosed, if necessary by a supplement to the application.

______________________________________                    ____________________

Insured’s signature                                                                               Date