About Your Boat
Year:
Make:
Model:
Length:	Feet     Inches
Engine Type:	Please Choose One In-Board Out-Board Stern Drive (I/O) Sail Boat Sailt Boat (Multi Hull) Jet Boat
Top Speed:
Number of Engines:
Hull Material:	PLEASE CHOOSE ONE Wood Fiberglass Aluminum Inflatable Steel Other - please explain in comment box below
Idle Steering Device Installed?	Please Choose One YES NO
Navigation:	Please Choose One INLAND WATER ONLY Coastal - 75 miles out max More than 125 miles from the coast
Liability Coverage:	Please Choose One $10,000 $20,000 $25,000 $30,000 $40,000 $50,000 $60,000 $100,000 COMBINED SINGLE LIMIT (CSL) $100,000/$300,000 $250,000/$500,000 $300,000 COMBINED SINGLE LIMIT (CSL) $500,000 COMBINED SINGLE LIMIT (CSL)
Uninsured Watercraft Liability (BI):	Please Choose One $10,000 $20,000 $25,000 / $50,000 $30,000 / $60,000 $40,000 $50,000 / $100,000 $50,000 CSL $60,000 CSL $100,000 / $300,000 $300,000 CSL $500,000 CSL NONE - I REJECT THIS COVERAGE
Medical Payments:	Please Choose One No Coverage $1,000 $2,000 $3,000 $4,000 $5,000 $7,500 $10,000
Towing & Assistance:	Please Choose One No Coverage $500 $1,000 $2,000 $3,000 $4,000 $5,000
Other:	Physical Damage Coverage?: CHOOSE ONE No Coverage - Skip down to baoters safety Yes - Answer questions below
	If you want physical damage, please answer the following:
	Insured Value:
	Insured Value includes motors and equipment attached to the vessel, do you want to exclude these parts? Choose One No - Include Them Yes - Exclude Them
	Deductible: Choose one for phsyical damage 250 500 1000 2500 5000
	Protective Device: Choose One No Device Automatic Fire Extinguisher Alarm System (High Water/Fire/Theft) Central Station Monitoring System No Strike Lightening System
	Personal Property to be insured: $
	Any prior claims besides  towing?
	Boaters Safety Course:   CHOOSE ONE No Course Coast Guard Auxiliary Chapman Boating School Power Squadron Course Commercial Aviation Course Coast Guard Course Marine Pilots License State or Federal Accredited Maritime Academy Captains License Merchant Marine License State Administered Safety Course
Previous Insurance:	Yes - 6 months of continuous coverage Yes - 1 year of continuous coverage Yes - 2 or more years of continuous coverage Yes - but I have had a lapse of 30 days or more No
	Do you have any tickets or accidents in the last 3 years? Please place any other questions or comments here.

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