Name
DOB
Address
Occupation
City/St/Zip
Hm Phone
Wk Phone
Email
FAX
Boats Owned
Comments:
Detailed Information:
Boating/Sailing/Safety Classes
Other Experience
Previous Losses (3 Yrs)
Current Insurance Company
Name of Lender
Moorage Loc
Builder
Year
Type
Max Speed
Engine Manuf
Engine Yr
Single/Twin
Last Survey Dt
Survey By
Market Value
Repl Value
Auto Halon/CO2
VHF
SSB
Depth
GPS
Radar
WeatherFax
Other Nav
Length
Make/Model
H.P.
Navigation Limits
Paid Crew (if any)
Offshore Cruising/Racing Anticipated
Deductibles
1%
2%
Hull Value $
Liability $
Pers. Effects $
Medical $
Tender/Outboard $
Notes:
