- Your Name (R) Your Date of Birth (R)
- Corporate Name
- Mailing Address(R)
- City (R)
- State (R)
- Zip Code (R)
- E-Mail Address (R)
- Day Phone(R)
- Fax
- Your Occupation(R)
- Marital Status(R)
Yacht Sailboat Houseboat Powerboat Sportfisher - Vessel Type (R)
- Current Insurance Company (R)
- Policy Expiration Date (R)
- Years of Ownership (All Boats) (R)
- Years of Boating Experience(R)

- Previously Owned Vessels (include length and type) (R)
Safety Courses:
- Power Squadron - Coast Guard - ASA
- Other Safety Courses

USCG Licenses Held, If Any:
- 50 Ton - 100 Ton - 200 Ton

Will there be more than one owner (other than family members)? (R)
- Yes - No - Total number

Will there be any other operators apart from the owner? (R)
- Yes - No - Total number

Any Paid Captain or Crew Members? (R)
- Yes - No - Total number

Will the Vessel be Used for Chartering? (R)
- Yes - No - Total number of charters

Is this vessel a Liveaboard (Principle Residence) ?(R)
- Yes - No

Any Insurance Losses or Claims in the Past? If yes, Amount Paid, Approximate Date of Loss (R)
- Yes - No
- Details if Yes

Any Driving Tickets in the last 5 years for you or any operator of this vessel? (R)
- Yes - No
- Details if Yes
- Your Vessel Year (R)
- Vessel Length in Feet (R)
- Vessel Make (R)
- Vessel Model (R)
- Vessel Name (R)
Hull Material: (R)
- Fiberglass - Aluminum - Steel
- Other
0 1 2 3 - Gas (R) 0 1 2 3 - Diesel (R)
- Engine Make (R)
- Engine Year (R) - Horsepower (R) - Top Speed (R)
- Approximate Date of Purchase (R)
- Purchase Price (R)
- Last Survey Date - In-Water - Out-of-Water
- Summer Location (R)
- Winter Location (R)
Vessel Laid up? (R) - Yes - No
If Yes please indicate what dates the vessel is laid up.
From to
- Area of Navigation (R)
Please state below the limits of coverage you desire:
- Hull and Equipment (R)
- Deductible (R)
- Tender and Outboard(R)
- Trailer(R)
- Personal Effects (R)
- Medical (R)
- P & I Liability (R)
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