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Client information

Name:

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Date of birth:

Occupation:

Boating experience

Prior years of boating experience:

Sizes & types of boats owned and operated:

Prior boating claims and losses:

Boating safety courses completed:
USPS
USCG Auxiliary

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Boat information

New purchase

Purchase date:

Hull material:

Length:

Year:

Make:

Model:

Boat will be stored:
Trailer
Moored

Storage location:

Type of use:
Pleasure
Charter
Commercial
Live aboard

Primary area for use:

Dinghy/outboard/kicker motor:

Value:

Engine information

Type:
Inboard
Outboard
Inboard/outboard
Jet
Other

Configuration:
Single
Twin

Fuel:
Gas
Diesel

Total horsepower: Top speed:

Trailer

Year:

Make:

Value:

Value and coverage

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Liability coverage:

Other

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Additional Information

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Date:

02/06/2012