Date:
Referred by:
Name:
Address:
City: State: Zip:
Phone: Home Work
SS#: DOB: Occupation:
Are you a smoker or non smoker?
E-mail address:
Driver # 1: DOB
Driver # 2: DOB
Is there a policy in force now? Yes No Carrier: Exp. Date:
Any losses in the past 3 years? Yes No
Please comment:
Is this boat for pleasure or business use?
Years of experience: Years as a boat owner:
Year of boat: Make: Model:
Wood Fiberglass Length: Purchase price:
Engine size: Year: Make:
Is this engine inboard/outboard inboard outboard ?
Estimated MPH:
Do you use this boat in fresh water saltwater Both?
Current Value of boat and motor: Current value of trailer:
Any of the following safety features? VHF Radio Depth Finder
Radar/Loran Halon CO2 System
Any water-skiing or other towing activities? Yes No Any racing? Yes No
Are you requesting any personal effects coverage? Yes No
Principle place of mooring during season:
During off season:
Other types of boats owned/operated:
Desired coverages
Liability: $100,000 $300,000 $500,000
Physical Damage Deductible: $100 $250 $500
Please use this space below for any additional information that you would like us to have..