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Owner Information:

Boat Information:

Trailer Information:

Trailer Information:

Mooring Information:

Experience:

Date of Birth
Occcupation
Years of Boat Experience
Previous Boat Owned
Boating Safety Classes		Coast Guard Aux.
		USPS
		Other
USCG Licenses		6-Pak Charter
		100 Ton
		Masters
Please list any auto driving tickets, accidents, or DUI's past 3 years:

Please list boating claims, losses or accidents past 5 years

Navigation Limits:

Is Boat to be used for Private Pleasure Only?		Yes No
Is there a Paid Skipper / Crew?		Yes No
Will this boat be used for Charter, Rental, or Leasing?		Yes No
Will this boat be used as a Residence or Live aboard?		Yes No
Do you have this boat currently for sale?		Yes No
Is this boat currently insured?		Yes No
If yes, name of insurance company
Expires
Is this boat owned by a Corporation?		Yes No
If yes, provide legal name of Corporation:

Has this boat ever been damaged?		Yes No
If yes explain:

Has insurance ever been cancelled or refused?		Yes No
If yes explain:

Latest Survey Date
		In Water
		Haul Out

Coverage Request:

Purchase Date
Total Purchase Amount
Boat & Motor Current Value
Trailer Current Value
Distance to Shore
Liability Amount	100.000
	300.000
	500.000
	1.000.000
Deductible	1%	250
	2%	500
	3%	1.000
Note: Deductibles and Liability Limit will be quoted at closest amount available to amount selected
If more then two (2) unrelated owners please explain:

Other Comments: