Current Boat/Watercraft Insurance Information

Company Name (not agency): Policy Expiration Date:   Premium Amount: $ Term: 6 Months   1 Year   Other:

Coverages (input only for those desired)

Type Sums Insured Type Sums Insured Hull- Physical Damage $ Tender / Dinghy $ Liability Coverage $ Crew Liability $ Owner / Operator M&C $ Medical Payments $ Commercial Passenger Liability $ Uninsured Boater $ Trailer $ Personal Property $ Non-Emergency Towing $ Other $

Vessel Information

Vessel Name: Manufacturer/Model:   Year   Length Date Purchased Purchase Price $ Present Value $ Max Speed mph   Registration # Hull Identification #: Waters to be navigated: Tenders or Dinghies: Storage Address (Street, City, Co., St.): LAID UP: From: to On Shore Afloat Stored on Trailer: Y   N Will be trailered over 100 miles: Y   N

Equipment (please select ALL equipment on your Boat/Watercraft)

Bilge Pumps CO2/Halon System Aux Generator, Diesel EPIRB Fume Detector Aux Generator, Gas Sonar Fire Extinguishers Other (list below) Depth Sounder Cooking Stove LORAN/ Direction Finder Engine Alarm GPS Anti-theft Devices Radar Life Raft SATNAV/ OMEGA Ship to Shore Radio

Miscellaneous (please check ALL that apply)

Primary Power Type of Hull Hull Material Fuel Tank Sail Sailboat Wood Metal Outboard Performance Metal Fiberglass Inboard Runabout Fiberglass     Inboard/ Outdrive         Other

Engine/Outboard Motor Information (please complete for each engine)

Eng H.P. Gas Diesel Year Date Purchased Purchase Price Present Value 1 $ $ 2 $ $ 3 $ $   Manufacturer/Model Serial Number 1 2 3

Trailer Information

Year Date Purchased Purchase Price $ Present Value $ Manufacturer/Model: Serial #:

Operators (always list insured as Operator #1)

#  Name DOB Auto DL # State Social Security # USCG/Power Squadron Certificate 1 2 n/a 3 n/a # Auto Violations/Suspensions in last 5 years: Years of Boat Ownership: 1 2 3

Boat/Watercraft Usage

#  Explain all YES responses in REMARKS Yes/No  #  Explain all YES responses in REMARKS Yes/No 1 Is the boat chartered to others with captain? Y N 6 Is the boat used commercially or for business purposes? Y N 2 Is the boat chartered to others without captain? Y N 7 Does the applicant employ a paid crew? If so how many? Y N 3 Is the boat used for racing? Y N 8 Was any operator involved in a marine loss in the last 10 years (insured or not)? Y N 4 Is the boat used for water skiing or diving? Y N 9 Was any coverage declined, cancelled or non-renewed during the last 5 years? Y N 5 If the boat is used for fare paying passenger charters, what is the average number of passengers per trip?     Number of trips per year? REMARKS

Additional Comments

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