| How did you hear about us?: |
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| First Name: |
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| Last Name: |
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| Address: |
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| Address 2: |
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| City: |
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| State: |
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| Zip Code: |
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| Phone Number: |
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| Email Address: |
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| Boat Year: |
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| Boat Manufacturer: |
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| Length of Boat: |
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| Boat Model: |
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| Make of Engines: |
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| Number of Engines: |
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| Total Combined Horsepower: |
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| Top Capable Speed: |
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| If Custom State WHO built: |
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| Engine Type: |
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| Year of Engine(s): |
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| Please check box if applicable: |
Supercharged |
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Fixed Fire System |
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Fume Detector |
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GPS |
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DUI (or any other MAJOR violation) in past 5 years |
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Commercial Use |
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Vessel Used in racing/speed contests |
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Closed Canopy Vessel |
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Live Aboard |
| Please list boating courses taken: |
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| Date of Birth: * |
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| Lay up Start Date: |
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| Lay up End Date: |
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| Purchase Mo/Year: |
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| Purchase Price: |
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| Year of Trailer:: |
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| Trailer Manufacturer: |
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| Value of Trailer:: |
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| Deductible Requested: |
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| Agreed Value of Boat: |
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| Liability Limit Requested: |
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| List prior boats owned by Year/Length/Make: |
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| Navigational Territory: |
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| If there are other operators of the boat please list name and date of birth here: |
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| Explain any prior boat claims (past 5 years): |
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| New Purchase? Check here |
Check here if your boat is a new purchase |
Current Carrier:
Do not complete if new purchase |
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Current Annual Premium:
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| Total Yrs Boating Experience: * |
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