Full Name:
Address:
City: State: Zip:
Phone Number:
Email:
Contact Name (if different):
Effective Date:
Vessel Waters Navigated:
Marina:
Layup: Yes No Time Period: to
VESSEL INFORMATION:
Year: Make: Model:
Serial/Hull #:
Motor(s):
Motor Type: HP:
Motor(s) Serial #:
Size of Boat: Hull Material:
Fair Market Value: Limit of Liability (Comprehensive & Collision):
DRIVER INFORMATION:
Name: D.O.B.:
Driver’s License #:
S.S. Number:
Have you had any accidents in the last 3 years? Yes No If yes, how many?
Have you owned a vessel prior to this year? Yes No If yes, years experience:
Present Carrier:
Premium:
