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Client information

Insured Name: *

E-mail address: *

Address: *

Address 2:

City / State: *

Zip: *

Home phone:

Work:

Cell:

Other:

Married or Single? *
Married       Single

Homeowner? *
Yes       No

Date of birth: *

Occupation:


Boating experience

Prior years of boating experience: *

Sizes & types of boats owned/operated: *

Prior boating claims and losses: *

Boating safety courses completed:
USPS    
USCG Auxiliary
State Boaters Card

Other courses or training:


Boat information

New purchase

Purchase date: *

Hull material: *

Length: *

Year: *

Make: *

Model: *

Boat will be stored: *
    Moored

Storage location: *

Type of use: *



Primary area for use: *


Engine information

Type: *



Configuration: *

Fuel: *


N/A

Horsepower (each): *