Your Information
Name
*
Phone
Email
*
Address
City
State
Zip Code
Date of Birth
Boat Information
Year
Make & Model
Hull Value or Purchase Price
Length of Vessel
Hull ID Number
Hull Material
Fiberglass
Wood
Other
Other
Year, Make and HP of Engine
Fuel Type
Gas
Diesel
Other
Other
Max Speed
Insurance Coverage Requested
Amount of Hull Insurance
*
Hull Deductible ....(of Hull Value)
1%
2%
Watercraft Liability
$300,000
$500,000
Other
Other
Medical Payments ($2,000 up to $5,000)
Trailer Value
Navigation Area
Navigation Period
8 months
12 months
Mooring or Marina Name
Mooring or Marina Address
Is vessel used commercially?
*
Yes
No
If vessel is used commercially please describe the operation
Operator Information
Year and Length of Prior Vessels
Years of Boating Experience
Loss Experience Past Five Years
Miscellaneous Information
Currently Insured By
Is Vessel for Sale?
Yes
No
Purchase Price of Vessel $
List Safety Gear
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