Current Insurance Carrier*:

How long?

Expiration Date:

Marital Status:

SS#:

Drivers License#:

Number of years experience:

Member of any boating assoc.?

Purchase price:

Loss Payee:

Name:

Address:

City:

State:

Zip: 

Balance due:

Has insured ever been declined?:

If yes, please explain:

List and detail any losses or claims:

Year:

Length:

Model:

Builder:

Hull ID#:

Name of boat:

Hull type*:

Hull material*:

If hull material other, specify:

Engine*:

Year:

How many?

Manufacturer:

HP each:

Max Speed (MPH):

Engine(s) S#:

Trailer Year:

   Length:

Manufacturer:

Serial #:

Tender Year:

    Length:

Manufacturer:

Serial #:

Tender's Motor Year:

   Length:

Manufacturer:

Serial #:

Loran: Yes No   Radar: Yes No   Halon: Yes No

GPS: Yes No   Depth Finder: Yes No   VHF: Yes No

Other:

Chesapeke Bay Trib.:

Inland waters:

Atlantic Coast

between

and

Vessel will be laid up*:

Vessel in excess of 24' Only ever transported overland:

If yes, how many miles?

Chartered?

Ever used for water skiing?

Coverage effective period from:

to