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Vessel must meet the following criteria:
26' or above in length, Value of $40,000 or Higher, Maximum Age of 12 years
*Fields required
Personal Information
Name Insured
Date Of Birth
Marital Status
Home Phone
  
Work Phone
Mobile Phone
Fax
Email Address
Street Address
City
State
Zip
Valid Driver's License #
Social Security #
Years of Experience
 
Courses
 USCG USPS Other:
Moving Violations (in last 5 years for operator #1)
Additional Operator
Additional Operator Date of Birth
Additional Operator Experience
Additional Operator Moving Violations (in last 5 years for operator #2)
 
Hull Information
Type of Vessel
Year
Manufacturer
Model
Material
Length
Purchase Date
Cost including Equipment
New Replacement Cost
Prior Boats Owned
(Length & Manufacturer)
   
Machinery
Fuel Type
Year
Make
No. of Engines
Total H.P.
Max Speed
Propulsion System
   
Mooring / Lay-Up
Mooring Location
Navigation
City
State
  
Lay Up Period from
to
Laid Up at
Afloat
Ashore
Current / Prior Insurance Company
Premium
Exp. Date
   
Coverages
Hull & Equipment
Deductible
 Other
P & I Liability
Personal Umbrella Available
Trailer
Tender & Outboard
Survey Available
Survey Date

Equipment
(Check all the apply)
GPS
VHF
Loran
Radar
Depth Finder
Single Side Band
Automatic CO2/Halon
Autopilot
Sniffer
Burglar Alarm
Other
Describe Losses in the past 5 years (Date, Amount, Cause/Type)
   
Submitting Agency
Contact Name
Phone
Fax
   

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