Boat Insurance
Name*
Address*
DOB
Occupation
City/St/Zip*
Hm Phone*
Wk Phone
Fax
Email*
Boats Owned*
Comments:
Detailed Information:
Boating/Sailing/Safety Classes
Other Experience
Previous Losses (3 Yrs)
Current Insurance Company
Name of Lender
Marina additional insured
Name
Moorage Loc
Builder
Year
Type
Max Speed
Engine Manuf
Engine Yr
Single/Twin
Last Survey Dt
Survey By
Market Value
Repl Value
Auto Halon/CO2
VHF
SSB
Depth
GPS
Radar
WeatherFax
Other Nav
Tender: Yr
Length
Make/Model
Outboard: Yr
H.P.
Navigation Limits
Paid Crew (if any)
Offshore Cruising/Racing Anticipated
Deductibles
1%
2%
3%
other
Hull Value
Liability
Pers. Effects
Medical
Tender/
Outboard
Notes:
* denotes a required field
