Insured First Name*Last Name*Email* Phone*Postal Address* Street Address City State Postcode Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Date of Birth* DD slash MM slash YYYY How many years' experience do you have with a craft of a similar size/nature?When did you obtain your boat license?Not Applicable Do not have a boat licenseHave you recently purchased the vessel / in the process of purchasing the vessel?* Yes No Date of Purchase* DD slash MM slash YYYY Purchase Price*Current InsurerExpiry date of current cover DD slash MM slash YYYY Not currently insured Yes Not currently insuredHow did you discover Tudor Insurance*Select one...I am an existing client or I have had policies with Tudor in the pastI was referred to TudorGoogle SearchWho referred you to TudorVessel InformationYear*Make/Model*Type*Select oneCatamaranCruiserPowered DinghyHouseboatRigid Inflatable Boat (RIB)Kayak / RowboatJetskiSailing Dinghy / Off Beach CraftSki BoatSkiffTrailer SailerTrimaranWindsurferYacht / Keel boat / SloopOtherPlease Specify*Vessel Name*Sail/Reg. No.*Length (metres / feet)*Vessel Construction* Fibreglass Steel Timber Alum Rubber Carbon Fibre Plastic Ferrocement Other Please SpecifyDescription of Build* Stock Production Professional Custom Built Owner Built Kit Built Does the vessel foil?* Yes No Select one* Foiling is standard for my vessel class, my craft came with foils Foiling is standard for my vessel class, however I had to purchase an aftermarket foil kit for my craft Foiling is not standard for my vessel class, I was able to purchase an aftermarket foil kit for my craft Is the craft professionally built?* Yes No Motor 1 - Main* Yes Not Applicable This field is hidden when viewing the formSection BreakMotor 1 - Main*YearMake/ModelH/PSerial Number* Inboard Outboard Petrol Diesel Steam Max Speed* Up to 20kts Up to 60kts Over 60 kts This field is hidden when viewing the formSection BreakMotor 2 - Auxillary* Yes Not Applicable Motor 2 - Auxillary*YearMake/ModelH/PSerial NumberTrailer* Yes Not Applicable What is the length of the trailer?*(in metres)Trailer*YearMake/ModelReg.No.Mast Construction* Yes Not Applicable Mast Construction* Timber Aluminium Plastic Carbon Fibre Other Rigging Construction* Yes Not Applicable Rigging Construction* Stainless Steel Rod Synthetic Other Age of riggingDate rigging last replaced DD slash MM slash YYYY Date rigging last serviced, if different DD slash MM slash YYYY Equipment/accessories (i.e. sports/fishing gear, beach trolley, safety equipment)*Total Sum Insured*Is there any additional information you wish to advise* Yes No Specify*Cruising Limits* Standard: Australian waters up to 200nm Other Specify*Do you intend on permanently living on board your craft?* Yes No Stored* Backyard Garaged Marina / Mooring Pen Swing Mooring Yacht Club Compound/Racking Storage Location* Street Address City State Postcode Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Third Party Liability* $10,000,000 (Standard) $20,000,000 Yacht Club Racing* No Up to 25nm Up to 50nm Up to 100nm Up to 200nm More than 200nm Do you race under a spinnaker?* Yes No Is waterskiers liability required?* Yes No In the last 5 years:Have you had any Pleasurecraft Insurance claims?* Yes No This field is hidden when viewing the formSection BreakDOL* DD slash MM slash YYYY Type of Loss*mast damage from vessel capsizing whilst racingClaim Amount*This field is hidden when viewing the formSection BreakHave you been convicted of any criminal offences?* Yes No Specify*Have you been declared bankrupt?* Yes No Specify*Have you had an Insurer refuse to renew/ cancelled or terminated a policy?* Yes No Specify*Have you had special conditions imposed under the policy?* Yes No Specify*For any vessels over 5 years of age, please provide recent photographs of the craft and survey/pre-purchase report (if available). Drop files here or Select files Accepted file types: pdf, jpg, Max. file size: 72 MB. This field is hidden when viewing the formWhat you told usThis document sets out your answers to questions which may be relevant to the decision of an insurer to accept the risk (refer to your duty of disclosure) and the insurance covers which you require us to attempt to arrange. Please review the information in accordance with your duty of disclosure and advise us immediately if any of the details are incorrect or incomplete. You may confirm the information is correct and complete by doing any of the following: (a) Signing and returning a copy of this form; or (b) Providing us with instructions to place the policy of insurance.This field is hidden when viewing the formSignatureThis field is hidden when viewing the formNameThis field is hidden when viewing the formDateCAPTCHANameThis field is for validation purposes and should be left unchanged.
