Name:
Address:
City, State, Zip:
Phone Number:
E-Mail:

---

Current insurance company name:

Expiration date:

Coverage Information:

Liability Limits: Choose one of the following options: $50,000 per person/&100,000 per accident/$25,000 property damage $100,000 per person/&300,000 per accident/$50,000 property damage $250,000 per person/&500,000 per accident/$100,000 property damage $100,000 Combined Single Limit $300,000 Combined Single Limit $500,000 Combined Single Limit

Medical Payments to Others: Choose one: No Medical Payments $1,000 per person $2,000 per person $5,000 per person

Physical Damage Coverages:

Deductible	Boat Length	Type of Craft	Weight of Boat
Choose one: $50 $100 $250 $500 $1,000 $2,500		Choose one: Runabout Cabin Cruiser Pontoon Ski Boat Sailboat Houseboat Bass Boat

---

Ship Information:

Boat...

Year	Make/Model	Hull	Where Used	Insured Value
		Choose one: Fiberglass Wood Metal	Choose one: Inland Waters Oceans Great Lakes Inter-coastal

Motor...

Year	Make/Model	Engine	Horsepower	Insured Value
		Choose one: Outboard In/Outboard Inboard Sailboat

---

Driver Information:

Driver #1 Name	Birthday	Sex	Marital Status	Year Licensed
		Choose one: Male Female	Choose one: Married Unmarried
Safety Courses: Yes No		If Yes, list course:

Accidents and Violations:

Does any driver have any accidents or violations? Yes No
If yes, please list all accidents and violations in the past 3 years...

Date	Driver's Name	Type of Occurrence
		Choose one: none Speeding<15MPH over Speeding>15MPH over DWI At-fault Not-at-fault Other
Date	Driver's Name	Type of Occurrence
		Choose one: none Speeding<15MPH over Speeding>15MPH over DWI At-fault Not-at-fault Other
Date	Driver's Name	Type of Occurrence
		Choose one: none Speeding<15MPH over Speeding>15MPH over DWI At-fault Not-at-fault Other

To which association do you belong? Choose one: None Boats USA International Power and Sail Association Marina Storage National Boat Owners Association Vessel Assist Associatin of America Yacht Club Member Other Association

---