Skip links
Skip to content
Home
About
Fleet
Asset Tracking
Careers
Contact
Toggle navigation
Home
About
Fleet
Asset Tracking
Careers
Contact
OPERATORS RESUME OF EXPERIENCE & MEDICAL HIST
Name of Operator
(Required)
Date of Birth
(Required)
MM slash DD slash YYYY
Address
(Required)
Married
(Required)
Yes
No
Homeowner
(Required)
Yes
No
City
(Required)
State
(Required)
Zip
(Required)
Phone
(Required)
Email
(Required)
Employer
(Required)
Drivers License Number
(Required)
State
(Required)
Occupation
Licensed Captain
(Required)
Yes
No
Tonnage
# of Years Licensed
Prior boats you have OWNED and/or OPERATED: COMPLETE ALL CATEGORIES
1.
Boat type
Owned
Operated
Mat
Length
Manufacturer
# Years
Vessel Use
Charter
Commercial
Recreational
2.
Boat type
Owned
Operated
Mat
Length
Manufacturer
# Years
Vessel Use
Charter
Commercial
Recreational
3.
Boat type
Owned
Operated
Mat
Length
Manufacturer
# Years
Vessel Use
Charter
Commercial
Recreational
4.
Boat type
Owned
Operated
Mat
Length
Manufacturer
# Years
Vessel Use
Charter
Commercial
Recreational
Waters Navigated:
N Atlantic
S Atlantic
Florida
Gulf of Mexico
Pacific
Alaska
Great Lakes
Other
Waters Navigated: (other)
Please list all marine incidents you have been involved with; including vessels damaged or passengers, crew or other third parties injured while you were acting as captain in the past five years (If none, write “None”):
Add
Remove
Please list all automobile infractions you have been involved with; including accidents, tickets and restrictions within the past three years (If none, write “None”):
Add
Remove
Have you ever been convicted of a felony?
Yes
No
Please advise date, the event and penalty
Have you undergone surgery in the past five years?
Yes
No
Please advise date and type of surgery:
Have you ever been injured on the job?
Yes
No
Please advise date of injury & disposition of claim:
List all marine insurance claims and/or prior marine loss history in past 5 years (If none, write “None”):
Add
Remove
Consent
I HEREBY AFFIRM THAT ALL STATEMENTS MADE HEREIN HAVE BEEN ANSWERED TO THE BEST OF MY ABILITY AND ARE TRUE.
Signature
Date
MM slash DD slash YYYY
Adding {{itemName}} to cart
Added {{itemName}} to cart
Loading...
