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Customer Information |
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First Name: |
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Middle Name:
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Last Name:
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Sex: |
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M
F |
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Date of Birth: |
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Social Security Number:
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Phone Number:
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Home Address: |
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City, State, Zip Code: |
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Marital Status: |
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Married
Single
Other |
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Email Address: |
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Primary Residence: |
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Own
Home/ Condo |
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Own Mobile Home: 10 years old or newer |
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Rent |
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Live with Parents |
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Other |
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Driving Record (prior 35
months) |
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Number of/ Nature of Tickets (all vehicles) |
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Number of/ Nature of AF/
NAF Auto and Boat/ PWC Accidents: |
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Automobile Driver License
Status: |
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Boat Information |
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Type (i.e., pleasure,
fishing, sail, etc.): |
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Year: |
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Make: |
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Model: |
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Length: |
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HIN #: |
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Number of Engines: |
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Total Horsepower
(excluding trolling and kicking motors): |
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Propulsion Type |
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Inboard: |
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Outboard: |
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Inboard /Outboard: |
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Jet: |
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Hull Material: |
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Enhanced Performance
Modifications (i.e., blowers, superchargers, etc.): |
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Trailer Coverage: |
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Yes
No |
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Rating Base* (include
value of trailer and portable boating equipment if
coverage desired): |
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*Purchase price with taxes and title fees for TLR
coverage or current market value for A/V, ACV coverage |
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Underwriting
Information |
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Dockage/ Mooring/ Storage
ZIP Code: |
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Watercraft Use (i.e.,
pleasure, business, etc.): |
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Multi-Owner (more than one
owner not in the same household): |
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Yes
No |
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Other Policies (5%
Discount) |
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Automobile: |
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Boat/ PWC: |
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Motorcycle/ ATV/
Snowmobile: |
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RV: |
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Name of Regular Operators:
(Any operator with regular access to insured vehicle
more than 12 times a year) |
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Names of Household
Resident Operators: |
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Coverage Information |
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Hull Coverage (Comp &
Collision): |
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Total Loss Replacement (new boats only) |
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Agreed Value |
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Actual Cash Value |
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Hull Deductibles (Comp &
Collision): |
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$250 |
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$500 |
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$1,000 |
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$2,500 |
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$5,000 |
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Liability Coverage Limits:
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Uninsured/ Underinsured Boater Coverage: |
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Medical Payments Coverage: |
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$1,000 |
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$2,500 |
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$5,000 |
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$7,500 |
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$10,000 |
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Primary Personal Effects
Coverage: |
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$1,000 |
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$2,000 |
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$3,000 |
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$4,000 |
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$5,000 |
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Fishing Equipment Coverage
(Primary): |
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$1,000 |
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$2,500 |
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$5,000 |
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$10,000 |
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Emergency Towing
(on-water): |
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$300 |
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$500 |
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$1,000 |
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$2,500 |
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Coastal Navigation: |
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75
Nautical Miles |
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125 Nautical Miles |
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