MOORING AREA INSURANCE STATEMENT

Date_____________

Name: __________________________________

Member No.: ____________________________

Boat Name: ____________________________

Boat Length: _____________Depth: __________

I hereby state to Raritan Yacht Club knowing that it will rely upon my statements:

1. That my boat is insured with ______________________________________ (name of company). (If boat not insured, I have filled in blank with the work “None”);

2. That I have determined such insurance is adequate;

3. That I have named the Raritan Yacht Club as additional insured on my policy (if I have insurance);

4. That if I have a mooring, I will make sure that my mooring is maintained in a safe condition and is adequate for my boat;

5. That I will take care to properly secure my boat to my mooring, if I have a mooring. and will otherwise secure my boat against wind, weather and tide;

6. That I take care to inform myself of the rules of the Raritan Yacht Club and that I will abide by the rules of the Raritan Yacht Club;

7. That to the extent permitted under my boat insurance policy, I will hold Raritan Yacht Club, its flag, officers, board members, committee chairpersons, members and employees, harmless against any claim or suit arising out of loss, damage or personal injury incurred by myself or others as a result of the use of my boat or my use of any vehicle or equipment of any kind whether in the water or in storage or otherwise.

Signature ___________________________________