Taylons App

Please complete this form to the best of your ability. Leave fields blank if information is unavailable.

Registered Owner

DBA or LLC Name (If Applicable)

DOB

U.S. Citizen

Marital Status

CELL Phone #

E-MAIL

example@example.com

Residence

Address

Physical Address

Street Address Line 2

CityState

ZIP

Occupation

Vessel to be Insured Information: Year

Length

Manufacturer

Model

Fuel Type

Engine Type

Engine Year/ MFG/ Model

# Of Engines

Total HP

Purchase Price

Date Of Last Survey

Trailer Year/ Manufacturer

Trailer Value

Hull Value Requested (Include Engines & Electronics)

Hull Deductible Requested

Liability Limit Requested

Personal Effects & Fishing Equipment

Medical Payments

Uninsured Boaters

Is This Vessel Used As A Live-Aboard

Mooring Location

Name Of Marina

Type Of Mooring

Mooring Address

Describe All Waters Navigated And Max Mileage Offshore

Will the Vessel Be Used Year-Round?

Any Driving Violations in the Last Three Years?

Other

Are you a Licensed Captain?

Is the Vessel Owner Operated?

Do You Employ A Captain?

Do You Employ Crew?

Is This Vessel Used for Charter or Any Commercial Use?

Additional Operators

Additional Operator & DOB

Street Address Line 2

Additional Operators Experience Years Operating

Boating Claim History if any?

Claim 1

Detail of Claim

Street Address Line 2

Date of ClaimAmount Paid

Status

Claim 2

Detail of Claim

Street Address Line 2

Date of ClaimAmount Paid

Status

Previous Boating History Boat #1

Boat #1 Information

Manufacturer

Street Address Line 2

Year Length

# Of Years Operated/ Owned

Previous Boating History Boat #2

Boat #2 Information

Manufacturer

Street Address Line 2

Year Length

# Of Years Operated/ Owned

Previous Boating History Boat #3

Boat #3 Information

Manufacturer

Street Address Line 2

Year Length

# Of Years Operated/ Owned

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