Insured Information

This wont take long. Please fill out the following information about yourself.

Date Reffered By Corporate Owner (if applicable) Insursed's Name

Mailing Address

Street Address City State Zip Code E-mail Address Phone Number

Boat Information

Please fill out some information about the boat you are wanting to insure.

Year Length Make Model Hull Type Weight

General Information

Storage/Mooring Location Details Storage/Mooring Address Zipcode Purchase Price $ Date of Purchase Lay Up Dates Start Lay Up Dates End Date of Last Survey Where is the boat stored? Indoor Outdoor Dry Afloat

Engine Information

Engine's Make/Model # of Engines Year Fuel Top Speed Exposed Motor? Yes No If Yes, Is there a physical separation between engine and passengers? Yes No Date of Last Survey Engine Type OB IB V-Drive I/O Jet Drive

Coverage Requested

Deductible(s)

Hull Information

Insuring Amount P&I Liability Medical Personal Property Uninsured Boaters Towing

Trailer Information

Trailer Amount Trailer Year Trailer Make

Vessel Information

HIN Trailer VIN Engine Serial(s)

Tender Information

Dingy Amount Dinghy Year Dinghy Make Dinghy Length Dinghy Motor Dinghy HP

Prior Boats Owned

Please add the length, Make, Year, Speed & Years Owned.

Select how many prior boats owned 1 2 3 4

Owner Operator Resume

Mandatory Information Years of Experience Years of Ownership Experience Boating Courses USPS/USCG Tres Martin Teague Other Insured's Occupation Insured's Age Driver's License Number State Martial Status Date of Birth Captain's License Areas of Navigation International Waters Coastal Use Yes No

Owner Operator Resume Continued

Home Owner? Yes No Commercial Use Yes No Paid Crew Yes No DUI/OUI Yes No Number of Charters Number of Tickets