Please provide the following information. Click here for more information about Boat Insurance.
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Personal Information
*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: $25,000 per person/&50,000 per accident/$10,000 property damage $50,000 per person/&100,000 per accident/$50,000 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
Select: $50 $100 $250 $500 $1,000 $2,500		Select: Runabout Cabin Cruiser Pontoon Ski Boat Sailboat Houseboat Bass Boat

Ship Information:
Boat...
*Year	*Make/Model	*Hull	Where Used	Insured Value
		Select: Fiberglass Wood Metal	Select: Inland Waters Oceans Great Lakes Inter-coastal

Motor...
*Year	*Make/Model	*Engine	*Horsepower	*Insured Value
		Select: Outboard In/Outboard Inboard Sailboat

Driver Information:
*Driver #1 Name	*Birthday	*Sex	*Marital Status	*Year Licensed
		Select: Male Female	Select: Married Single
Safety Courses: Yes No If Yes, list course:

Driver #2 Name	Birthday	Sex	Marital Status	Year Licensed
		Select: Male Female	Select: Married Unmarried
Safety Courses: Yes No If Yes, list course:

Driver #3 Name	Birthday	Sex	Marital Status	Year Licensed
		Select: Male Female	Select: 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 Occurence
		Choose one: none Speeding<15MPH over Speeding>15MPH over DWI At-fault Not-at-fault Other
Date	Driver's Name	Type of Occurence
		Choose one: none Speeding<15MPH over Speeding>15MPH over DWI At-fault Not-at-fault Other
Date	Driver's Name	Type of Occurence
		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

How did you hear about us?
Please select one:
Referral	Newspaper	Mailing	Other (please type in answer)