Trailer?:
Own
Rent
Main Operator First Name:
*
Main Operator Last Name:
*
Address:
City:
State:
Zip Code:
Phone Number:
Alternate Phone Number:
E-mail Address:
*
Do you rent or own your home?:
Own
Rent
Have you moved in the last 60 days?:
Yes
No
Gender
Male
Female
Marital Status
Single
Married
Divorced
Widowed
Do you have a checking account?:
Yes
No
Number of operators to insure (including yourself):
*
List boats main operator and any additional operator’s age, name and whether operator has completed Coast Guard Auxiliary/Powered Squadron Course:
Is the boat currently insured?:
Yes
No
Current Policy Expiration:
Current/Desired Policy Deductible:
Boat Type:
Use:
Vessel Storage Location:
Waters Navigated:
Personal Property Insurance:
Used for racing?:
Yes
No
Hull Make/Model:
Type:
Length:
Estimated Market Value:
Year Built:
Max Speed in MPH:
Personal Effects:
Misc. Boating Equipment:
Trailer?:
Yes
No
If Yes, Make and Value:
Engine 1 Make:
Engine 1 Year:
Engine 1 Type:
*
Fuel 1 Type:
Est. Value 1 (O/B Only):
Horse Power 1:
Engine 2 Make:
Engine 2 Year:
Engine 2 Type:
Fuel 2 Type:
Est. Value 2 (O/B Only):
Horse Power 2:
Liability:
Medical Payments:
Water Ski Medical Needed?:
Yes
No
Any listed operators involved in boating accident within the past 5 years; boat and/or equipment suffered damage within past 5 years; or any listed operator involved in auto accident or received moving traffic citation in last 3 years?:
Yes
No
If yes, please describe:
Check this box to grant our agency permission to secure your credit and/or claim history, for insurance purposes only, under the Fair Credit Reporting Act.
Yes, secure my credit and/or claim history
How would you describe your credit rating?:
Excellent
Good
Average
Poor
Submit
Should be Empty: