Boat Insurance
Customer Information
Name
E-mail
Street address
City
County
State
Zip Code
Home Phone
Work Phone
FAX
Boat Description
Make of Boat
Year Built
Boat Length
Present Hull Value
Purchase Date:
Hull Type
-- select --
Fiberglass
Wood
Territory
-- select --
Inland Lakes
Pacific Ocean
Class
-- select --
Type of Boat...Type of Power
Runabout.......Outboard or none
Runabout.......Inboard
Runabout.......Inboard/Outboard
Runabout.......Jet Drive
Cabin Cruiser..Outboard
Cabin Cruiser..Inboard
Cabin Cruiser..Inboard/Outboard
Cabin Cruiser..Jet Drive
Canoe,Dinghie..All
Sailboat.......Any Type of Supplemental Power
Sailboat.......None
Catamaran......Any Type of Supplemental Power
Catamaran......None
Houseboat......Outboard or None
Houseboat......Inboard
Houseboat......Inboard/Outboard
Pontoon........Outboard
Personal Watercraft....0-300 CC's
Personal Watercraft..301-500 CC's
Personal Watercraft..501-700 CC's
Personal Watercraft..701 & over
Personal Watercraft..Jet Drive Boat(under 16')
Components Description
Component
Make
Year
Value
HP
Inboard or In/Outboard
Outboard 1
Outboard 2
Trailer
Additional Rating Information
Simultaneous Motor Use?
Yes
No
Diesel Engine?
Yes
No
Automatic Fire Extinguishing System?
Yes
No
Additional Boat Equipment $
Personal Effects Coverage $
Maximum Speed (MPH)
Operators Age
Operator Class
Primary OPR Years Exp........Under 21 OPR?
3 or More Years...................No
More than 1 but less than 3.......No
1 or Less.........................No
3 or More.........................Yes
More than 1 but less than 3.......Yes
1 or Less.........................Yes
Boating Education
Organization................Course
U.S.Coast Guard.............Boating, Sailing & Seamanship
U.S.Coast Guard Auxiliary...Boating Skills & Seamanship
U.S.Coast Guard Auxiliary...Advanced Boating Classes
U.S. Power Squadron.........Boating (outboard,inboard,sail)
U.S. Power Squadron.........Advanced Boating Classes
Captain's License
NASBLA......................Boating Safety
Requested Coverages
Liability Limits
Medical
Physical Damage Deductible
-- select --
$100,000
$250,000
$300,000
-- select --
$1,000
$2,000
$5,000
-- select --
$50
$100
$250
$500
$1,000
$2,500
Have you had any losses within the last three years?
Underwriting Information
Current Insurance
Expiration Date
