OPERATOR INFORMATION
* indicates required fields
|
|
*Name: |
|
|
*Address: |
|
|
*City: |
|
|
*State: |
|
|
*Zip: |
|
|
*Day Phone (w/ area code): |
|
| Eve. Phone (w/ area code): |
|
| Fax (w/ area code): |
|
|
*Email Address: |
|
|
*Occupation: |
|
|
*Date of Birth: |
|
|
*Boating Experience: |
Years |
| Current Insurer: |
|
| Policy Expires: |
|
| Premium: |
|
|
| Boat Name: |
|
|
*Manufacturer: |
|
|
*Model: |
|
|
Power Sail |
|
*Year Built: |
*Length: |
|
*Hull Material: |
|
|
*Number of Engines: |
*Total HP:
Top *Speed: |
|
*Engine Manufacturer: |
|
|
*Fuel: |
|
|
*Check all that
apply: |
VHF Radio
GPS
Radar
Bilge Alarm
Auto Alarm
Fume Alarm
Depth Finder
Anti-Theft Devices
Auto Pilot
Halon or
CO2
Other |
|
| Last Survey Date: |
|
|
In Water Out of Water |
| Surveyor's Name: |
|
| Date of Last Haul Out: |
|
|
*Market Value: |
|
| Replacement Value
New: |
|
| Boating Courses Completed: |
|
|
*Previous Vessels Owned: |
|
|
*Mooring Location: |
|
|
*Describe your area of
navigation: |
|
|
|
*Purchase Price of Watercraft: |
|
|
*Date of Purchase: |
|
|
*Live Aboard: |
Yes No |
|
*Amount of Hull Insurance
Desired: |
|
|
*Liability Coverage: |
Other: |
|
*Hull Deductible: |
|
| Tender Value: |
|
| Outboard Value: |
|
| Personal Effects Amount: |
|
| Trailer Value: |
|
|
*Boating Losses in Last 5 Years: |
Yes No |
*Is there a
Lay-up Period?
ie: 11-1 to 4-1 |
thru |
| (If yes, explain): |
|
| Boating Courses: |
|
|
*Driving Record: |
|
|
|
|
|
|
