Contact Information

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Name *
Address *
City
State
Zip Code
Date of Birth
Email *
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Home Cell Business
Secondary #
Home Cell Business

Watercraft #1

Year
Make
Model
Driver's license number
Boat condition
Hull Length
Hull Material (Roplene, carbon fiber, and rotomolded technologies should be classified as Fiberglass)
Propulsion Type
Number of Motors(do not include trolling motors)
Total Horsepower (If more than one motor, add the horsepower of all motors to determine total. Do not include kicker or trolling motors.)
Primary Use (Pleasure use exclusively/Racing Speed Contests/Business Commercial/Rented or Leased to Others/Primary Residence)
Watercraft Zip Location (where watercraft is located for majority of year)
Own or lease?
What year was this watercraft acquired?
Market Value of Watercraft(enter whole dollars only) (include all motors and add value of trailer if coverage is requested)

Residency

Primary Residence:
Moved in the last 2 months?

Driving History

Years Boating Experience

Accidents, Violations, and Claims

As a driver in the last 3 years, have you had any of the following regardless of fault (including automobile):

e.g.: hitting a car/object/property/animal, car hits you, weather, vandalism, theft, hail

Tell us about your insurance...

Insurance History

Additional Information

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