Basic Address Information

Name:
Address:
City:		State:		Zip:

Home Phone:		Business Phone:
Fax:		E-mail:

Vessel information:

Boat Type: Outboard Inboard Inboard/Outboard Water Jet Sail

Name of Waters Navigated:

Engine Type: Diesel Gasoline Twin Engine: Yes No

Built in Automatic Fire Extinguisher: Yes No

Outboards, Inboards, Inboard-Outdrives or Sailboats (Top Speed of: mph)

Include miscellaneous boating equipment in the value of all boars. (Not sports equipment)

Property	Year Built	Manufacturer	Model and Serial Number	Length (ft)	H.P. Each Engine
Boat
Motor				--------------
Trailer				--------------	-----------------

Property	Amount of Insurance	Hull Class
Boat
Motor		----------------------------------
Trailer		----------------------------------

Desired Deductible: None $25 $50 $100 $250 $500

Liability:

A. Bodily Injury & Property Damage Liability:	Per Occurrence:
B. Medical Payments:	Per Occurrence:
C. Uninsured Watercraft:	Per Accident:

Optional Coverages:

Emergency Towing & Assistance: $ per emergency (no deductible applies)

Sceheduled Boating Equipment

Deductible: None $25 $50 $100

Equipment Schedule:

Description	Value

Operator information:

Principal Operator:

Occupation:

Other Operators (List All):

Use:

Distance traveled when trailered: How Often:

What experience has owner had in operating a boat of this type?

If navigated in the Great Lakes or Ocean, indicate prior experience:

Safety Courses completed (you will be asked to mail or fax copies of certification):

U.S. Coast Guard: Boating Skills and Seamanship Basic Boating Principles of Sailing

U.S. Power Squadron: Basic Piloting Small Boating

Outboard boat maximum horsepower rating:

Used for waterskiing? Yes No

Number of hand fire extinguishers on board:

Complete the following for inboards, inboard-outdrives and sailboats:

Boat is: Cabin Cruiser Open cockpit Houseboat

Is fuel tank filling pipe arranged so fuel overflow will drain overboard? Yes No

Present value including all equipment: $

Date Purchased:

New or Used?

Cost to Applicant: $

If purchased Used, approximate cost new: $

Where is the vessel laid up?

Where can boat be inspected?

Ocean going boats - operated more than 75 miles from coast? Yes No

Loss History:

Have you ever had a boat/yacht insurance claim?
Yes No, explain:

Your request for a quote or the form