Name: *

Date of Birth: *

How did you hear about us? *

Address:

City, State, Zip:

Home Phone:

Work Phone:

Email: *

Are you a 6-Pack Fishing Charter? *

Yes   No

Watercraft Information

Year *   Manufacturer *  Model *

Length *   ft.   in.   Beam:

Hull Material:

Fiberglass Aluminum Wood

Total # of Engines: *

Type: *

Houseboat Runabout Pontoon Deckboat Cruiser
Other* (details)

* If Other please explain:

Engine #1: *

Make *  Model *  Year * HP *

Engine #2:

Make     Model    Year    HP

Type: *

Outboard   Inboard I/O Jet Sail Aux None

Is your engine: *

Gas   Diesel

Trailer:

Year    Make

Dinghy:

Year   Make   ft.   in.   $ Value

Dinghy Motor:

Year Make HP $ Value

Equipment:

Depth/Fish Finder   Stainless Prop   GPS

Anti Theft Trailer   Anti Theft Boat   Anti Theft Prop

VHF Radio   Vapor Detector   Auto Halon/CO2

Lay-up Dates: to    Ashore Afloat

Purchase Date: *

Total Purchase Price: *

Operator's Experience

Total years of boat ownership: *    Total years of operating experience: *

Licenses Held:

Previously owned boats:

Make   Model    HP    Years Owned

Make    Model    HP    Years Owned

Make    Model    HP    Years Owned

Boating Courses Completed & Year:

Any Watercraft Losses? *

Yes   No

If yes:
Date   Circumstances   $ Amt. Paid

Date   Circumstances   $ Amt. Paid

Date   Circumstances   $ Amt. Paid

Any Auto Violations or Suspensions? *

Yes   No

If yes:
Date   Circumstances

Date   Circumstances

Date   Circumstances

Intended Use

Vessel Uses: *

Private Pleasure   Liveaboard (Primary Residence)
6-Pack Fishing Charter   Other* (details)

If Other please explain:

Waters Navigated: *

Inland   Great Lakes   Coastal   Chesapeake Bay ONLY
Other* (details)

If Other please explain:

State where vessel is kept. *    Zip: *

Coverage Desired

Hull & Equipment:

$

Engine #1:

$

Engine #2:

$

Trailer:

$

Dinghy Motor:

$

Towing Limit:

$ ($500 standard)

Personal Effects:

$ ($2500 included)

Watercraft Liability: *

$50,000   $100,000   $300,000   $500,000   $1,000,000

Deductible: *

1% (Standard)   2%   5%

Optional Coverage

Pacific Cup Race Endorsement What's this?
NAVIGUARD™ MBI What's this?

Current Insurance

Issuing Company:

   Exp. Date:

Current/Renewal Premium:

$

Has vessel been continuously insured for the past 12 months?   Yes   No

If "No" please explain: