Name:          	
Email:         	
Address:     	
County:		     
City/State/Zip:	
Work Phone:    	
Home Phone:    	

Comments and Questions:



When was the boat purchased?:
                       

Name of insurance company,
if currently insured:  

Expiration date of insurance policy,
if currently insured:  

Have you had any prior boating losses or claims?
Yes  No
If "Yes", please explain:


Boating Ownership Details: 
Please let us know the make, model and size of the 
boats that you have owned. Indicate the years
that you owned them.


Birth Date of Principal Operator:
                           
Occupation:                 
How Many Years Boating Experience?: 

Boating Experience Details: 
Please let us know the make, model and size
of the boats that you have experience operating.  
Indicate the years that you operated them.


Has the Principal Operator been cited for
any traffic violations in the last 4 years?
Yes  No
If "Yes", please explain:



Your Small Boat Information
Vessel Make:  	  	
Vessel Model:  	  	
Year Built:  	  	
Length (Feet): 	  	 
Engine Make:  	  	
# of Engines:  	  	
Fuel:  	          	
HorsePower (each):		
Is the boat on a trailer?  Yes  No

Navigation Area: (Check all that apply)
Fresh Water       Salt Water
Bahamas           Other


Summer Mooring Location: 
Winter Mooring Location: 
Lay-Up Period: (If Any... Enter the Dates of Lay-up)
                         

Total Value (Boat/Motors/Trailer):  

Deductible      
    $250 
    $500 
    $1,000


Liability Limit 
    Select One
    $100,000
    $300,000
    $500,000 
    $1,000,000 


You may now: