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Preparer's Information Who are you?: Select One Agent Dealer Insured  * Name:  * Phone Number:  * Ext: E Mail Address:  * Fax Number: Producer # (if applicable):   Insured's General Information Boat Owner's First Name:  * Boat Owner's Last Name:  * Street Address:  * City:  * State: Select One Alabama Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Nova Scotia Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming  * Zip:  * DOB:  * Occupation: Years/Boating:  * Years/Ownership:  * Length & Make prior Vessels Owned:  * Length & Make other Vessels Operated:  * Courses completed (certificate required): None      USCG USPS On-Line Captain Use Ctrl key for Mutli Select Driver's License Number: MVR Driving Record Last 3 Yrs: Select One Clean 1 Minor 2 Minor 1 Major 2 Major 2 Major +  * Boat Losses/Claims in past 5 years (If Any: Date/Amt):   *     Vessel / Engines / Storage / Usage Information New purchase?: No Yes Purchase Price:  * Purchase Date:  * Is Boat Currently insured?: Yes No * Boat Year:  * Manufacturer:  * Model:  * Boat Type: Select One Air Boat Bass Boat Bowrider Cabin Cruiser Center Console Cuddy Deck Boat High Performance Homemade Houseboat Jet Boat Kit Boat Motor Yacht Non Powered Pontoon Runabout Sailboat Sailing Yacht Ski Boat Sportfish Trawler Walkaround  * LOA (ft.):  * Weight (lbs.): Hull type: Select One V Hull Trimaran Keel Flat Catamaran  * Hull Material: Select One Composite Fiberglass Steel Wood  * Engine(s) year:  * Engine(s) Manufacturer:  * Fuel type: Select One Gas Diesel  * Number of engines: Select One 1 2 3 4  * H/P ea:  * Engine Type: Select One Inboard I/O Outboard Jet Drive Open Motor  * Top speed (mph):  * General Nav. Area: Select One Atlantic Chesapeake Bay Florida Florida / Bahamas Great Lakes Gulf Inland Pacific  * Intended Use: Select One Private pleasure Commercial Full time live-aboard 6 Pac Charter Occasional Charter  * Mooring Location (in season): Select One Marina Residence Private Dock Commercial Storage  *   If commercial or charter use, provide detailed comments at end of form Mooring Address (City, State, Zip, County):  * Layup (out of season): NoneAshore AfloatBoat lift * Layup Start Date: Layup End Date: Layup Location: Select One Marina Residence Commercial Storage         Safety / Anti-Theft Equipment (credits may apply for each item checked)   Compass   Auto-fire system GPS Fume detector   D/F   O/D or O/B locks Radar CO2 detector   VHF / Cell   Prop locks EPIRB Smoke alarm     Anti-theft alarm   Trailer locks   Coverage / Limits Requested (standard limits may apply) Hull & Machinery value: $  * Deductible amount: $ Select One 1% 2% 3% Other  * Liability limit: $ Select One 100,000 300,000 500,000 1,000,000 Other  * Personal Property limit: $ 500 1,000 2,500 5,000 10,000 15,000  * Medical Payments limit: $ Select One 1,000 2,000 3,000 5,000 10,000 25,000 Towing: $ Select One 300 400 500 1000 1500 Uninsured Boater limit: $ Select One 100,000 300,000 500,000 1,000,000 Other Trailer Value: $ Dinghy / Tender value: $ Fuel Spill Coverage:   No Yes Water Sports Coverage:   No Yes Other Coverage Requests:   Additional Comments or Explanations