Please fill all the required fields – as indicated by the red asterisk *

 
Person Submitting Request --- Name:   Email Address : 
 

Insured Name and Address

First, M.I., Last *:     
Street *:   
City, State, zip*:    
Occupation: 
Birth date* (mm/dd/yyyy): 
 
Social Security #:
Multiple unrelated owners* (Y/N):   
Owner Vessel Loses* (Y/N):   
Loss Date (most recent) (mm/dd/yyyy):
Loss Description (amount, etc.):
 

Principal Operator Interrogatories

US Coast Guard Lic.* (Y/N) :  Commercial use* (Y/N) :   
Courses taken* (Y/N) :    # Speeding tickets in last 7 years* : 
Paid Captain* (Y/N) :  DUI in last 7 years* (Y/N) : 
Experience (in years)* : 
  Charter Days Annually* :  Charter Type
Youthful Operator(s) (25 and under)* (Y/N) :  # of Charter Crew:  # Passengers
Description of Charter (e.g., fishing only, etc.): 
 

Vessel to Be Insured

Year*:    Length*:   
Manufacturer*:  Model*:  
Vessel Type*: Hull material*: HullType*:  
Years Owned?*:    Purchase Date* :    Purchase Price*:  
Engine Mfg :  Engine Year* :  Number of Engines* : 
HP Per Engine* : HP Total Vessel* :  Max. Speed*:
Engine Type :  Fuel Type :  Modified Engine?: 
Raced Non-Club* (Y/N):   Live Aboard* (Y/N):  
 

List Prior Boats You Have OWNED or OPERATED Other Than Vessel To Be Insured

Year*:  Length*:  Manufacturer*:  Model: HullType:  Owned or Just Operated?*:  Years Owned/Operated?*: 
 
Navigation section
Mooring State*:  General Navigation*:  Specific Navigation Warranty*: 
 
Mooring and Lay-Up information (if any)
Mooring at Residence (Y/N)*:  Marina*: 
Mooring City*:  Mooring Zip code*: 
Layup Type (if any) :  From (mm/dd/yyyy)  To (mm/dd/yyyy) 
 

Insurance Coverage Requested
Effective date(mm/dd/yyyy)* : 
Insured Value* :  
Deductible Option* : 
Liability Coverage Option* :  
Trailer : 
Tender : 
Comments (up to 250 characters) :