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OPERATOR INFORMATION #1
Name:
Birthdate:
Sex (M/F):
# Years U.S. Licensing:
Be specific to tell if accidents are "at-fault" or "NOT-at-fault" - (carriers require proof on NOT-at-fault accidents); Also, be specific as to TYPE of violations, and approximate DATES of each in the fields below:
Number & Type of Accidents last 3 years:
Number & Type of MINOR violations last 3 years:
Number & Type of MAJOR violations last 3 years:
Number of Years Boating Experience:
OPERATOR INFORMATION #2 (if none, leave blank)
Name:
Birthdate:
Sex:
# Years U.S. Licensing:
Be specific to tell if accidents are "at-fault" or "NOT-at-fault" - (carriers require proof on NOT-at-fault accidents); Also, be specific as to TYPE of violations in fields below:
Number & Type of Accidents last 3 years:
Number & Type of MINOR violations last 3 years:
Number & Type of MAJOR violations last 3 years:
Number of Years Boating Experience:
VESSEL & UNDERWRITING INFORMATION
Year of Boat:
Make & Model (be specific):
Boat Length:
Hull Type (wood, Metal, fiberglass, etc):
Max. Speed (in MPH):
Market Value: $
Engine Make:
Engine Type:
(Inboard, I/O, Jet)
Engine Horse Power:
Fuel Type:
(Gas, Diesel, etc.)
Trailer Cov. Needed?
Yes
No
Yr./Make/Model of Trailer:
Trailer Value: $
Where is boat
moored or stored?
Describe waters boat taken on?
Describe boat
general usage? (fishing, ski, etc.)
VESSEL COVERAGES:
Limits of Liability:
$15/30 BI / 10 PD
$25/50 BI / 15 PD
$50/100 BI / 25 PD
$100/300 BI / 50 PD
$250/500 BI / 100 PD
Hull Coverage:
NO Coverage
$250 Deductible
$500 Deductible
$1000 Deductible
Water Ski Medical Coverage?
Yes
No
Uninsured Motorists Cov.?
Yes
No
Comments or Remarks:
(List additional drivers, special coverages, etc. here)
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