No Boats over 15 years of age accepted - No current Programs for Alaska or Hawaii
- Owner Information -
First Name:      MI:   Last Name:
Address:
City:    State:    Zip:
Phone:() -    Fax Number: () -
E-mail Address:  
   
- Boat Information -
Year:    Length:    Builder:
Model:   Vessel Type:   Top Speed:
   
- Engine Information -
Year:   Make:    # Of Engines:
HP Each:    Type:    Fuel:
   
-Trailer Information -
Year:    Make:   No. of Axles:
   
Indicate Equipment / Safety Features Installed on Your Vessel:
VHF Radio SATNAV C0-2
Fume Detector SSB GPS
Auto Halon Depth Finder Radar
Loran EPIRP Fish Finder
   
- Mooring Information-
Mooring/Storage Location:    Mooring City:
Mooring State:    Mooring Zip:
- Experience -
Date of Birth:   Occcupation:
Years of Boat Experience:   Previous Boat Owned:
Boating Safety Classes: Coast Guard Aux.   USPS   Other   
USCG Licenses:   6-Pak Charter    100 Ton    Masters   
Please list any auto driving tickets, accidents, or DUI's past 3 years:
Please list boating claims, losses or accidents past 5 years:
   
Navigation Limits:
Is Boat to be used for Private Pleasure Only? Yes     No
Is there a Paid Skipper / Crew? Yes     No
Will this boat be used for Charter, Rental, or Leasing? Yes     No
Will this boat be used as a Residence or Live aboard? Yes     No
Do you have this boat currently for sale? Yes     No
Is this boat currently insured? Yes     No
If yes, name of insurance company: Expires:
Is this boat owned by a Corporation? Yes     No
If yes, provide legal name of Corporation:
Has this boat ever been damaged? Yes     No
If yes explain:
Has insurance ever been cancelled or refused? Yes     No
If yes explain:
Latest Survey Date:     In Water     Haul Out
   
- Coverage Request -
Purchase Date:      Total Purchase Amount:
Boat & Motor Current Value:   Trailer Current Value:
Liability Amount: 100,000 300,000 500,000 1,000,000
Deductible: 1% 2% 3% 250 500 1,000

Note: Deductibles and Liability Limit will be quoted at closest amount available to amount selected
If more then two (2) unrelated owners please explain:
- Other Comments -
How did you hear about Boater's Insurance?   
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