*  Name :       *   e-mail address:

*  Street :  *  City:  *  State:  *  Zip:

*  Phone # :   Mobile # :

Driver's  to be listed on this policy:

* Driver 1 : Date of Birth :   Social Security# Driver’s License # :

     Relationship to insured :  Years of Boating Experience : Married : Yes No

   Driver 2 : Date of Birth :   Social Security# Driver’s License # :

     Relationship to insured :  Years of Boating Experience : Married : Yes No

 Violation Information: any tickets or accident?

  Last 3 years (minor violations) Speeding, turn, stop sign, red light, etc. Accidents - non chargeable, Accidents - chargeable
  Last 5 years (major violations) Major violations - drunk driving, reckless, hit and run, etc. Please include dates...

  Driver 2: 

Boat Information:

*Year : Make :   Model :    Body Style :    

   Hull Material :  Length : Maximum Speed :  Value $ : 

  Serial # / Hull Id :       Registration # :     

  Is trailer included in value of boat? s Yes No   Boat use  : Pleasure Residence Racing Fishing Charters other

*Motor Information 

Motor 1

  Year : Make :   Model :   Horsepower: 

 Inboard / Outboard / IO :   Gas or Diesel :      Serial # :

Motor 2

  Year : Make :   Model :   Horsepower: 

  Inboard / Outboard / IO :   Gas or Diesel :      Serial # :

*Trailer Information 

  Year : Make :   Model :     Value :       

*Safety Devices:

*Current or Prior Insurance Company :   Expiration Date of Policy:

Any Lapse in Coverage? No Yes

*  Date the policy is to take effect:

* Has the driver taken any safety courses ? : Yes No

  Coverages