Boat Insurance Application

GENERAL INFORMATION

Effective Date:	Effective Date: *
Named Insured (Applicant)	Named Insured (Applicant): *
Mailing Address:	Mailing Address: *
City:	City: *	State:	State: *
Zip:	Zip: *	Date of Birth:	Date of Birth: *
Residence address:	Residence address:
City:	City:	State:	State:
Zip:	Zip:	Email:	email:
Home phone:	Home phone:	Business phone:	Business phone:
Cell phone:	Cell phone:
Ever charged with operating a vehicle/vessel while intoxicated or under the influence of alcohol or drugs?			Ever charged with operating a vehicle/vessel while intoxicated or under the influence of alcohol or drugs?:
Details:	Details:
Years & details of boating experience:	Years & details of boating experience:
(Include length, manufacturer & years owned/operated):		(Include length, manufacturer & years owned/operated):
Boating/safety courses/licenses:		Boating/safety courses/licenses:
Marine accidents/losses, last five years:		Marine accidents/losses, last five years:
(Include date, description & amount of damages/settlement)		(Include date, description & amount of damages/settlement):
Insurance ever cancelled, declined or refused?:		Insurance ever cancelled, declined or refused?: Yes No
Intended waters of navigation:	Intended waters of navigation:
Primary mooring location:	Primary mooring locatio:
City:	City:	State:	State:
Zip:	Zip:	Security:	Security:
Layup?	Layup?: Yes No	If Yes: Ashore Afloat From:	If Yes: Ashore Afloat From:
to	to:	Location:	Location:
City:	City:	State:	State:
Zip:	Zip:	Security:	Security:
Vessel ownership, per title:	Vessel ownership, per title:
Manufacturer:	Manufacture:	Model:	Model:
Year built:	Year built:	Length:	Length:
Hull type:	Hull type:	Hull material:	Hull material:
Vessel name:	Vessel name:
Documentation/Registration number:	Documentation/Registration number:	VIN:	VIN:
Purchase price:	Purchase price:	Purchase date:	Purchase date:
Year of last survey:	Year of last survey:	Total horsepower:	Total horsepower:
Power type:	Power Type:
Number of motors:	Number of Motors:
Fuel	Fuel:
Motor year(s):	Motor year(s):	Motor manufacturer:	Motor manufacturer:
Any existing damage to vessel?	Any existing damage to vessel?: Yes No	Details:	Details:
Safety/security equipment on vessel	Safety/security equipment on vessel:
Live aboard?	Live aboard?: Yes No	Is vessel raced?	Is vessel raced?: Yes No
Age of rigging:	Age of rigging:	Maximum speed:	Maximum speed:
Paid captain/crew?	PAID CAPTAIN/CREW?: YES NO	Details:	Details:
Commercial use?	Commercial use?: YES NO	Details:	City:
Has vessel sustained any loss in last five years?	Has vessel sustained any loss in last five years?: YES NO	Details:	Details:
Any additional pertinent information:	Any additional pertinent information:
Tender manufacturer:	Tender manufacturer:	Model:	Model:
Year built:	Year built:	Length:	Length:
Purchase price:	Purchase pric:	Purchase date:	Purchase date:
HIN:	HIN:	Horsepower:	Horsepower:
Motor manufacturer:	Motor manufacturer:	Motor year:	Motor year:
Is tender towed behind vessel?	Is tender towed behind vessel?: Yes No
Mortgagee:	Lienholder:
Mailing address:	Mailing address:
City:	City:	State:	State:
Zip:	Zip:
Additional Insured:	Additional Insured:
Mailing address:	Mailing address:
City:	City:	State:	State:
Zip:	Zip:	Interest:	Interest:
Requested Hall value:	Hull requested agreed value:	Deductible:	Standard deductible:
Named Storm deductible:	Named Storm deductible:
Tender coverage:	Tender coverage:
Towing coverage:	Towing coverage:
Personal Effects coverage:	Personal Effects coverage:
Protection & Indemnity coverage:	Protection & Indemnity coverage (combined single limit):	Pollution coverage:	Pollution coverage:
Uninsured Boater coverage:	Uninsured Boater coverage:	Med Pay coverage:	Med Pay coverage:
Freeze Damage coverage?	Freeze Damage coverage?: Yes No	Crew Liability coverage?	Crew Liability coverage? : Yes No
Charter coverage?	Charter coverage?: yes No