Type of Boat * Houseboat Pontoon Fishing Boat Yacht Jetski Sail Boat Cabin Cruiser Runabout
Year *
Make *
Model *
Length in Feet *
Hull Material * Fiberglass Aluminum Inflatable Steel Wool Other
Type of Motor * Inboard Outboard Inboard/Outboard Jet
Year *
Make *
Model *
Total Horsepower *
Year (Optional)
Make (Optional)
Model (Optional)
Maximum Speed *
Year Purchased
Are You the Original Owner? Yes No
Where is the Boat Navigated? * Inland Water Ocean
Where is the Boat Stored? * Parking Lot Lift In-Water Yard Driveway Garage Other
Storage/Mooring Zip Code *
Market Value of Watercraft (including boat and motor) *
Market Value of Trailer
Boat/PWC Use * Pleasure Use Exclusively Racing/Speed Contests - Sail Only Business/Commercial Rent/Leased to Others Live - Aboard Primary Residence
Have You Had Boat Liability in the Past 12 Months? * Yes No
If So, Who Was the Insurance Carrier?
Number of Drivers * 1 2 3 4 5 6
Number of Years Boating Experience? - Driver 1
Gender - Driver 1 * Male Female
Marital Status - Driver 1 * Single Married Domestic Partner Separated Divorced Widowed
License State - Driver 1 * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Drivers License Number - Driver 1 *
Gender - Driver 2 Male Female
Marital Status - Driver 2 Single Married Domestic Partner Separated Divorced Widowed
License State - Driver 2 Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Drivers License Number - Driver 2
Number of Years Boating Experience?
Gender - Driver 3 Male Female
Marital Status - Driver 3 Single Married Domestic Partner Separated Divorced Widowed
License State - Driver 3 Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Drivers License Number - Driver 3
Number of Years Boating Experience? - Driver 3
Gender - Driver 4 Male Female
Marital Status - Driver 4 Single Married Domestic Partner Separated Divorced Widowed
License State - Driver 4 Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Drivers License Number - Driver 4
Social Security Number - Driver 4
Number of Years Boating Experience? - Driver 4
Gender - Driver 5 Male Female
Marital Status - Driver 5 Single Married Domestic Partner Separated Divorced Widowed
License State - Driver 5 Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Drivers License Number - Driver 5
Number of Years Boating Experience? - Driver 5
Gender - Driver 6 Male Female
Marital Status - Driver 6 Single Married Domestic Partner Separated Divorced Widowed
License State - Driver 6 Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Drivers License Number - Driver 6
Number of Years Boating Experience? - Driver 6
Any Tickets, Accidents, or Losses For Any Driver in the Last 3 Years? * Yes No
If Yes, Who? Give a Brief Explanation of What Happened.
Type of Coverage * Liability Only Liability and Physical Damage
Collision Deductable * Liability Only Liability and Physical Damage
Bodily Injury Limits * $25,000/$50,000 $50,000/$100,000 $100,000/$300,000 $250,000/$500,000
Property Damage Limits * $25,000 $50,000 $100,000 $250,000
Uninsured Boated Limits $25,000/$50,000 $50,000/$100,000 $100,000/$300,000 $250,000/$500,000
Comprehensive Deductible $500 $1,000 $2,500 $5,000
