Primary Owner Experience
Years of boating experience
Years as a boat owner
Size of boats operated	feet        feet        feet
Size of boats owned	feet        feet        feet
Boating Education	-Select- None USPS USCGA Other
Active Member	None USPS USCGA Other
Drivers License Number	State
List any moving violations by Owner within the last 3 years.
Date    Violation -Select- None DWI BWI Reckless Driving Refused Breath Test Speeding Suspension Other Date    Violation -Select- None DWI BWI Reckless Driving Refused Breath Test Speeding Suspension Other Date    Violation -Select- None DWI BWI Reckless Driving Refused Breath Test Speeding Suspension Other Date    Violation -Select- None DWI BWI Reckless Driving Refused Breath Test Speeding Suspension Other
Number of owners, other then yourself
Number of regular operators, other then yourself

Boat Information
Boat Hull Type	-Select- Bass Cruiser-power Houseboat Multihull-power Multihull-sail Personal Watercraft Pontoon Runabout Sail Trawler
Builder
Model
Year
Length	feet
Boat Name
Serial Number
Engine Year (YYYY)
Horsepower
Top Speed	mph
Hull Material	-Select- Fiberglass Aluminum Kevlar Wood Other
Power Type	-Select- Inboard Outboard Inboard/Outboard Jet Other
Fuel Type	-Select- Gas Diesel Electric None
Purchase Date	(mm/dd/yy)
Purchase Price	$
Insured Value	$
P&I Liability Limits	-Select- $100,000 $200,000 $300,000 $500,000
Trailer Value	$

Boat Location
Boat Location	-Select- On Land At Dock On Trailer On Mooring Other
Mooring	-Select- On Concrete On Helical On Mushroom Other
Marina Name or Boat Location
Marina or Boat Location Address
City
State	Zip

Insurance Information
Do you have this boat currently insured?	-Select- Yes No
Current insurance company
Current Premium	$
List claims or accidents within the past 3 years
Date    Claim -Select- None Sinking Theft of Boat Injury Struck Submerged Object Fire/Explosion Weather Theft of Equipment Collision Vandalism Other Date    Claim -Select- None Sinking Theft of Boat Injury Struck Submerged Object Fire/Explosion Weather Theft of Equipment Collision Vandalism Other Date    Claim -Select- None Sinking Theft of Boat Injury Struck Submerged Object Fire/Explosion Weather Theft of Equipment Collision Vandalism Other Date    Claim -Select- None Sinking Theft of Boat Injury Struck Submerged Object Fire/Explosion Weather Theft of Equipment Collision Vandalism Other
Boat usage	-Select- Coastal Ocean Open Ocean Fresh Water

Additional Comments

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