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Client information
Name:		E-mail address:
Address:	City:	State:	Zip:
Home phone:	Work:	Cell:	Other:
Date of birth:	Occupation:
Boating experience
Prior years of boating experience:

Sizes and types of boats owned and operated:		Prior boating claims and losses:

Boating safety courses completed: USPS USCG Auxiliary		Other courses or training:
Boat information
New purchase	Prior 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	Configuration: Single Twin	Fuel: Gas Diesel	Total horsepower: Top speed: mph knots
Trailer
Year:	Make:	Value:
Value and coverage
Total cost of vessel and engines:		Liability coverage:
Other
Existing insurance information:		Comments:
Submit 15
Submitted by:		Date:
		03/10/2010