PART ONE - Personal Information  
Name:          	
Email:         	
Address:     	
County:		     
City/State/Zip:	      
Work Phone:    	
Home Phone:    	

Comments and Questions:


When was the boat purchased?:
                       

What was the purchase price?:
                       

Name of insurance company,
if currently insured:  

Have you had any prior boating losses or claims?
Yes  No
If "Yes", please explain:


Expiration date of insurance policy,
if currently insured:      

Boating Ownership Details: 
Please let us know the make, model and size
of the boats and yachts that you have owned.
Indicate the years that you owned them.


Birth Date of Principal Operator:
                           
Occupation:                 
How Many Years Boating Experience?: 

Boating Experience Details: 
Please let us know the make, model and size
of the boats and yachts that you have experience
operating.  Indicate the years that you operated them.



Coast Guard or Power Squadron Course?:Yes  No

Has the Principal Operator been cited for
any traffic violations in the last 4 years?
Yes  No
If "Yes", please explain:


Your Boat or Yacht Information
Vessel Make:  	  	
Vessel Model:  	  	
Year Built:  	  	
Length (Feet): 	  	 
Engine Make:  	  	
# of Engines:  	  	
Fuel:  	          	
HorsePower (each):	
Is the boat on a trailer?  Yes  No
Auto/Halon or CO2 System?  Yes  No
Fume Detector?:	         Yes  No
CO Detector?:	         Yes  No

Check all that apply:
Loran             Radar
GPS/SAT           Compass
VHF               Life Raft
EPIRB             Depth Finder
Auto Pilot        Aux Generator
Theft/Fire Alarm  

Dinghy and Motor (If Applicable)
Do you have a dinghy?:   	       Yes  No
Value of Dinghy/Motor:   

Navigation Area: (Check all that apply)
Fresh Water       Salt Water
Bahamas           Other

Summer Mooring Location: 
Winter Mooring Location: 
Lay-Up Period: (If Any... Enter the Dates of Lay-up)
                         

Total Value (Boat/Motors/Trailer):


Deductible      
    1% 
    2% 
    3% 
    4% 


Liability Limit 
    Select One
    $100,000
    $300,000
    $500,000 
    $1,000,000 


Is the yacht a Liveaboard?  Yes  No
You may now: