Insured’s Information

Insured's Name

Email

Address

Phone

Fax

Boat Description

Year

Length

Builder/Make

Model

Hull Material

Name of Boat

Storage / Mooring Location:

Zip Code:

Purchase Price:

Date of Purchase:

Month:

Year:

Lay Up Period:

 Aflout Dry

 

Engine Information

Date of Last Survey:

 Aflout Dry

Engine(s): Make:

Number of Engines:

Year:

Total Horsepower:

Fuel:

Top Speed:

Supercharged:
 Yes No

Fume Detector:
 Yes No

Fixed Fire System:
 Yes No

Engine Type:
 Onboard Inboard I/O JET-DRIVE

Owner / Operator

Years of Experience:

Boating Courses:  USPS USCG Other

Driver's Licence Number:

State

Marital Status:  Single Married Divorced Separated Widow

Date of Birth: