Personal Information

Are you certified?  Select Yes No              If yes, what type? Select Captain CGA USPS

Insurance Information 

Have you ever previously had boat insurance?  Select Yes No

Are you currently insured for boat insurance?  Select Yes No

If yes, how many years with your present insurance company?  Select less than 1 1 2 3 4 5 6 7 8 9 or more

When does your insurance expire with your present company?  

Month: Select January February March April May June July August September October November December Day: Select 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year: Select 2004 2005 2006 2007

Have you ever made a boat claim?  Select Yes No   (If yes, explain in comments below)

Any driving violations in the past 5 years?  Select Yes No  (If yes, explain below)

Boat Information

Year: (enter 4 digit year)    Hull Type: Select Fiberglass Aluminum Wood Steel Boat Type: Select Runabout Open Fish Sport Fish Cabin Cruiser Trawler Sail Bass PWC Other

Engine Information

Equipment Information

Please check all that apply:  

VHF
Depth
Loran
Compass
Radar
GPS
EPIRB

Fume Detector: 

Select Yes No

Fire Equipment Type:

Select Automated Manual Both
 

Additional Insurance

Please check all that you wish to add or receive information:

Comments

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