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- Owner Information -
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First Name:
MI:
Last Name:
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Address:
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City:
State:
Zip:
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Phone:()
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Fax Number: ()
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E-mail Address:
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- Boat Information -
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Year:
Length:
Builder:
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Model:
Vessel Type:
Top Speed:
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- Engine Information -
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Year:
Make:
# Of Engines:
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HP Each:
Type:
Fuel:
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-Trailer Information -
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Year:
Make:
No. of Axles:
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Indicate Equipment / Safety Features Installed on Your Vessel:
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- Mooring Information-
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Mooring/Storage Location:
Mooring City:
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Mooring State:
Mooring Zip:
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- Experience -
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Date of Birth:
Occcupation:
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Years of Boat Experience:
Previous Boat Owned:
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Boating Safety Classes:
Coast Guard Aux.
USPS
Other
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USCG Licenses:
6-Pak Charter
100 Ton
Masters
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Please list any auto driving tickets, accidents, or DUI's past 3 years:
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Please list boating claims, losses or accidents past 5 years:
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Navigation Limits:
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Latest Survey Date:
In Water
Haul Out
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- Coverage Request -
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Purchase Date:
Total Purchase Amount:
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Boat & Motor Current Value:
Trailer Current Value:
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Liability Amount:
100,000
300,000
500,000
1,000,000
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Deductible:
1%
2%
3%
250
500
1,000
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Note: Deductibles and Liability Limit will be quoted at closest amount available to amount selected
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If more then two (2) unrelated owners please explain:
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- Other Comments -
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How did you hear about Boater's Insurance?
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Please Send Quote By: Email Fax Mail Phone
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