Please complete as much information as possible and click on "Submit Form" to forward your inquiry to our office. Information provided will be confidential and in no way obligates you to purchase insurance. In addition, by providing information, it does not represent an agreement on our behalf to provide insurance coverage.

Name Required
Street
City
State
Zip
Home Tel
Cell Tel
Work Tel
E-Mail Required

Current Agent/Ins. Co.
Renewal Date
Current Premium
Reason for changing companies

Boat Operator
Date of Birth

Motor Vehicle Record for Operator(s)
(include date(s) and description of accidents/violations)

List boating education classes:

Prior boats owned (include length):

Years of experience as a boat owner:

List any watercraft claims/violations:

Is there a paid captain or crew?  Yes   No

TELL US ABOUT YOUR BOAT

Year
Length
Manufacturer
Model
Hull Material	Fiberglass   Wood   Metal
Purchase Date

Purchase Price [vessel and motor(s)]:
Dinghy or Tender and Its Outboard Motor Value

ENGINE

Single or Twin
Gas or Diesel
Outboard, I/O, Inboard or Sail
HP per Motor
Year
Manufacturer
Maximum Speed

EQUIPMENT (Check all that apply)

 Loran

 Halon (co2)

 VHF

 Radar

 Anti-Theft

 GPS System

 Depth Finder

 Smoke Detector

 Compass

 Fire Extinguisher

WATERS OF NAVIGATION

Primary
Other waters

CURRENT COVERAGE

	Current Limits
Hull Equipment
Uninsured Boater
Tender
Personal Property
Trailer
Towing
Liability
Deductible	½%   1%   2%   3%
Medical Payments

Requested Lay-Up Period
Ashore     Afloat

Will the vessel be used for anything other than pleasure use?  Yes   No

If yes, please describe:

Will the vessel be used for water skiing?  Yes   No

Will the vessel be used for racing?  Yes   No

All of the insurance companies we represent determine your insurance score based on the information you have provided on this form.

Do you consent to our using the information provided to obtain
your insurance score?  Yes   No

ADDITIONAL COMMENTS