Current Policy Information
Agent:
Address:
City:
Policy Expiration Date:

Coverage(s) Information
Hull:	$
Liability Coverage:	$
Owner/Operator M&C:	$
Commercial Passenger Liability:	$
Trailer:	$
Uninsured Boater:	$
Personal Property:	$
Medical Payment:	$
Non-Emergency Towing:	$

Vessel Information
Vessel Name:
Manufacturer Model:
Hull Indentification No.:
Year:
Length:
Date Purchased:
Purchase Price:	$
Present Value:	$
Max Speed:	mph
Registration No.:

Engine Information
	Engine 1	Engine 2	Engine 3
Horsepower:
Gas/Diesel:	Select One Gas Diesel	Select One Gas Diesel	Select One Gas Diesel
Inboard/Outboard I/O:	Select One Inboard Outboard I/O	Select One Inboard Outboard I/O	Select One Inboard Outboard I/O
Manufacturer:
Serial:
Location of Vessel:
Tenders/Dinghies:
Waters Navigated:

Boat/Watercraft Equipment
Bilge Pumps:	Select One Yes No
CO2/Halon System:	Select One Yes No
Aux Generator, Diesel:	Select One Yes No
Aux Generator, Gas:	Select One Yes No
EPIRB:	Select One Yes No
Fume Detector:	Select One Yes No
Sonar/Radar:	Select One Yes No
Fire Extinguishers:	Select One Yes No
Depth Sounder:	Select One Yes No
LORAN:	Select One Yes No
Engine Alarm:	Select One Yes No
GPS:	Select One Yes No
Anti-Theft Devices:	Select One Yes No
Stereo System:	Select One Yes No
Life Raft:	Select One Yes No
SATNAV:	Select One Yes No
Ship to Shore Radio:	Select One Yes No
Other Equipment:

Miscellaneous
Primary Power:	Select One Sail Outboard Inboard Inboard/Outdrive Other
Type of Hull:	Select One Run About Performance Sailboat
Hull Material:	Select One Fiberglass Metal Fiberglass
Fuel Tank:	Select One Metal Fiberglass

Driver/Operator Information
	Driver 1	Driver 2	Driver 3
Name:
DOB:
Auto DL#:
State:	Alaska Alabama Arkansas Arizona California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska Nevada New Hampshire New Jersey New Mexico New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming	Alaska Alabama Arkansas Arizona California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska Nevada New Hampshire New Jersey New Mexico New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming	Alaska Alabama Arkansas Arizona California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska Nevada New Hampshire New Jersey New Mexico New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming
USCG/Power Squadran Certificate
Years of Boat Ownership:
Auto Violations/Suspensions in Last 5 Years:

Trailer Information
Year:
Date Purchased:
Purchase Price:
Present Value:
Manufacturer/Model
Serial #:

Boat/Watercraft Usage
Is boat a charter boat:	Select One Yes No
Is boat used commercially?:	Select One Yes No
Is boat used for racing?:	Select One Yes No
Will you be water skiing or diving with your boat?:	Select One Yes No
If you boat is used for charters, what is the average number of passengers and trips?:	per trip?: trips per year?:
If boat is used commercially, is there crew?:	Select One Yes No
Was any operator involved in a marine loss in the last 10 years (insured or not)?:	Select One Yes No
Was any coverage declined, cancelled or non-renewed during the last 5 years?	Select One Yes No
Additional Explanations:

Additional Information In the box below, please provide  any additional information  you feel may be necessary  for us to provide you with the best quote possible such as additional operators, coverages engines, etc.

Enter text above EXACTLY as it appears: