Personal Information
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| First Name Last Name DOB SS# |
| Mailing Address City State Zip Marital Status |
| Physical Address City State Zip Mooring Location |
| Home Telephone Email Address |
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| Boat Information |
| Year Make Model Hull Value Length Max Speed HP |
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| Power Type Engine Fuel Type Hull Material Hull Design |
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| Engine/Motor Information | | | | |
| Year Make Model | Engine/Motor Value | | | |
| Waters Navigated Years Experience Prior Boats Owned Safety Courses |
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| Safety Equipment Fire Extinguishers Depth Sounder Radar Anti-Theft Devices |
| Lay-Up Period Where is Boat Stored Trailer/Value of Trailer |
Driver Information
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| Is your license currently under suspension or revocation? | | | | |
| If so, is an SR-22 required? | | | | |
| Name | DL# & State | DOB | Sex | Marital Status Relationship |
| Driver 1 | | | | |
| Driver 2 | | | | |
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Have you had any accidents or violations in the last 5 years?
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| Violation Date | Violation Code |
| Driver 1 | | |
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| Driver 2 | | |
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| Boat Coverage Information |
| What limits of liability do you want quoted? | |
| Have you had continuous coverage for the past 6 months? | | | | |
Comprehensive Coverage
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| Deductable Boat 1 (if applicable) | |
| Deductable Boat 2 (if applicable) | |
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Collision Coverage
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| Deductable Boat 1 (if applicable) | |
| Deductable Boat 2 (if applicable) | |
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Remarks
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