Insured's First Name Insured's Last Name Street Address Address Line 2 City State Zipcode Country Email Phone Mobile Fax Occupation Requested Effective Date Boat Description Year Length Builder/Make Model Hull Material Weight Name of Boat Tender / Dingy YesNo If "Yes", Please Explain General Information Storage / Mooring Location Purchase Price Date of Purchase Laid Up Dates Dry IndoorsDry OutdoorsAfloat Date of Last Survey DryAfloat Engine Information Engine(s) 12 Make Year Total Horsepower Fuel GasDiesel Total Speed (MPH) Turbo YesNo Blower/Supercharger YesNo Fume Detector YesNo Fixed Fire System YesNo Engine Type OBINI/OJET-DRIVE Trailer Year Make Owner / Operator Resume Total Years of Boating Experience Total Years of Ownership Experience Driver's License Number Driver's License State Marital Status SingleMarried Boating Courses USPSUSCGOther Other Information Date of Birth Prior Boats Owned List the Waters or Areas you intend to Navigate Anticipated Trips Losses YesNo If "Yes" - Year of Loss Total Paid ($) Brief Description of Loss Current Insurance Carrier Premium Live Abroad YesNo Commercial Use YesNo Youthful Operators YesNo DUI (Last 5 Years) YesNo Paid Crew YesNo If Yes, # # of Charters 6 Pac12 Pac Driving Record for last 3 years as listed on MVR (Motor Vehicle Record) # Tickets # Accidents Additional Operators First Name Last Name Date of Birth # Prior Boats Owned / Operated First Name Last Name Date of Birth # Prior Boats Owned / Operated Coverage Required Hull Trailer ($) Liability ($) Additional Coverage Requested YesNo If "Yes" Please Explain How did you hear about us? 1+11=?
