Peter Laczko Insurance - Yacht and boats larger than 35 feet Form

YACHT AND BOATS LARGER THAN 35 FEET
Named Insured:*
Beneficial Owner (If Corpately Titled, Or Other Than Named Insured):
Insured's Email:*
example@example.com
Insured's Phone Number:*
Mailing Address:
Mooring Address:
Mooring Type:

TrailerDockLiftIndoor Dry StackOutdoor Dry StackMooring Ball
VESSEL INFORMATION
Year:
Manufacturer:
Model:
Length:
Hull Material:
Top Speed:
Date Purchased:
Purchase Price:
Number Of Engines:
Engine Year:
Manufacturer:
Total HP:
Engine Type:

InboardOutboardInboard/OutboardPODNone
Fuel Type:

GasDiesel
Safety:
Radar
GPS
Depth Sounder
Halon
GPS Theft Tracking:
Live Aboard
Do you have insurance now on a different boat
USE:

Personal PleasureCharter
Live Aboard:
Boating Course
Captains License
Date First Licensed

MonthDayYear
Date
PRIOR LOSS DETAILS (DATE, DESCRIPTION, AMT PAID)
Trailer Year:
Manufacturer:
Value:
Navigation Limit:
PRIMARY OPERATOR INFORMATION:
Name:
DOB:*

MonthDayYear
Driver's State:
Boating Course:
Captain's License:
Date First Licensed:
HomeOwner:
Marital Status:

MarriedSingleDivorcedWidowed
COVERAGE INFORMATION:
Currently Insured:
Current Hull Value:
Deductible:
Liability:
Towing:
Personal Effects Amount:
Lien Holder:
Should be Empty: