Owner information

Insured Name: *

E-mail address: *

Address: *

Address 2:

City / State: *
Select AL AK AR AZ CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

Zip: *

Home phone:

Work:

Cell:

Other:

Date of birth: *

Boating experience

Prior years of boating experience: *

Years of Ownership (all boats):

Sizes & types of boats owned/operated: *

Prior boating claims and losses: *

Boating safety courses completed:
USPS    
USCG Auxiliary
State Boaters Card

Yacht Club Member?
Yes        No

Other Affiliations:

Boat Information

Length: *

Year: *

Make: *

Model: *

Boat will be stored: *
Trailer     Moored

Storage location: *

Primary area for use: *

Engine information

Engine Make: *

Type: *
Inboard
Outboard
Inboard/Outboard
Jet
Non-Powered

Configuration: *
Single
Twin
N/A

Fuel: *
Gas
Diesel
N/A

Horsepower (each): *

Other Equipment:
VHF
DF
Fire Suppression
GPS
AutoPilot
EPIRB
Radar
Life Raft
CO Detector
Other

Value and coverage

Total cost of vessel and engines: *
(don't enter a $ sign or commas)
$

Deductible:
$

Liability coverage: *
Select $100,000 $300,000 $500,000 $1,000,000 $2,000,000 $5,000,000

Other

Prior insurance information:

Any Claims?

Comments:

Date: 11/21/24