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Watercraft Insurance

General Information
Name:
Address:
City:
State:
Zip Code:
Day Phone:
Night Phone:
Best Time To call  AM PM
Email Address
Current Boat/Watercraft Insurance Information
Company name(not agency)
Policy Expiration Date
premium amount
Terms  6 Month 1 Month other
Coverages
Type Sums Insured
Hull Pysical Damage
Liability Coverage
Owner / operater M & C
Commercial Passgener Liability
Trailer
Non - Emergancy Towing
Type Sums Insured
Tender / Dinghy
Crew Liability
Medical Payment
Uninsured Boater
Personal Property
Other
Vessel Information
Vessal Name
Year
Length
Date Purchase
Hull Identification #
Tender
Stored On Trailer  Y N
Will be trailed over 100 miles  Y N
Model
Purchase Price
Present Value
Max Speed
Registration
water to be nevigate
Storage Address
Miscellaneous
Please check the all the apply
Primary Power
 Sai
 Outboard
 Inboard
 Inboard/outboard
 other
Type Of Hull
 Saiboat
 Performance
 Runabout
Hull Material
 Wood
 Metal
 Fiberglass
Fuel Tank
 Metal
 Fiberglass
Trailer Information
year
Date Purchase
purchase Price
Present Value
Manufacture/ model
Serial #:
Operater
Name
DOB
Auto DL#
State
Social Security
UGSC/Power
Auto Violations/Suspensions in last 5 years Years Of
Boat Ownership
Boat / Watercraft Usage
#
1
2
3
4
Expalain all Yes responses in REMARAKS
Is the boat charactered to other with captain?
Is the boat charactered to other without captain?
Is the Boat used for racing?
Is the Boat used for water sikiing or diving?
YES/NO
 Y N
 Y N
 Y N
 Y N
5
6
7
8
Is the boat Used Commercially or for business purpose?
Does the applicant employ a paid crew? if show how many?
Ways any operator involved in a marine loss in the last 10 years.
was any converage declined, cancelld or non renewed during the last 5 years?
 Y N
 Y N
 Y N
 Y N
Remark
Additional Comments
Please give any additional commeent you fell appropriate for this quotation. if you have any additional information where there was not enough space please enter them here.
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