Insured's Name:		Effective Date:
Mailing Address:		Home Phone Number:
Social Security#'s:		Business Phone Number:
Garaging Address:

#	Drivers Name	DOB	Drivers License#	Tickets/ Accidents	Yrs Experience
1
2
3
4

Boat information
Year:		Make:		Model:
Value:		Hull ID#:		H.P
Max Speed:		Length:
Motor:	IB IB/OB OB	Included with boat	Yes No

If motor not included
Motor Year:		Make:
Model:		Value
Serial#:

Trailer Information
Year:		Make:		Model:
Value:		# of Axles:		Serial#:

Mooring Location
Name of Marina:
Address:
Lay Up Period:
Dry or Afloat?:	Dry Afloat

Additional Equipment:(type and value)

Boating Safety Coarse?:
Lienholder Name:
Lienholder Address:

Waters Navigated
Inland:
Great Lakes:
Other:

Current Carrier:			Exp. Date:
Policy #:
Liability Limit:		Uninsured Boater:

Medical Payments:	Yes No
Towing:	Yes No
Water skiing:	Yes No
Does Insured have a personal umbrella?	Yes No

DATE NEEDED:

Producer: