Boat - Yacht Applications : www.BoatingInsurance.com

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Boat Owner Information : Fields marked * are required
Last Name :*
First Name :*
Address :*
City :*
State :*
Zip Code :*
Home Phone :*
Work Phone :
Fax Number :
Email:*
Occupation :
Date of Birth :*
Driver's License :*
S.S. # :*
Married :*
Home Owner :*
Years Boating :*
Years Ownership :*	(includes all boats you have owned)
Last Largest Boat Owned to Date *	(Make/Length):
Present Insurance Company :
Current Policy Exp Date:*
Any Insurance Losses:*	(Last 3 Years):
If Yes Explain :
Dates of Loss :
Amount of Loss:
Which Insurance Company Was it With ? :
Boating Education :*
Boat Information :
Boat Purchased :*	Date Purchased:
Manufacturer :*
Model :*
Year :*
Length :*
Hull Material :*
Engine Type :*
Engine Type :*
Fuel Type :*
Engine Manufacturer :*
Engine HP :*
Top Speed :*	Mph
Equipment :	VHF Depth Finder Loran/GPS Radar Halon Fume Det Epirib Anti Theft Alarm
Trailer Make :
Trailer Year :
Trailer Value :
Tender?:*
Tender Value:*
Engine Manufacturer on Tender:
Coverages :
Coverage Type :*
Insured Value:*
Purchase Price :*
Deductible :*
Define Other Deductible :
Liability Limit:*
Defined Limit of Liability Other :
Personal Property Limit :*
Other Personal Property Limit :
Navigation Areas :*
Navigation Other :
Miles Offshore : (required)
Will Water Sports be Performed Using the Boat?:*
Lay Up Period :*
During Lay-Up :
Mooring Address :*	Same as home address
Mooring City :
County :*
Additional Coverage/Comments :
Do You Charter? :*
How Many Charters Per Year :
# Crew :
How Did You Hear About Us ? :
Do You Have a Recent Survey ? :
Boat Financed ?:
Bank/Finance Company :
Address :
Comments :