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Name*
DOB
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Hm Phone*
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Boats Owned*
Comments:     Detailed Information:   Boating/Sailing/Safety Classes Other Experience Previous Losses (3 Yrs) Current Insurance Company Name of Lender

Marina addt'l insured
Name				Moorage Loc
Builder				Year
Type				Max Speed
Engine Manuf				Engine Yr
Single/Twin
Last Survey Dt				Survey By
Market Value				Repl Value
Auto Halon/CO2		VHF		SSB
Depth		GPS		Radar
WeatherFax		Other Nav
Tender:    Yr		Length		Make/Model
Outboard: Yr		H.P.		Make/Model

Navigation Limits Paid Crew (if any) Offshore Cruising/Racing Anticipated

Deductibles		1%		2%		3%		other
Hull Value  $
Liability  $
Pers. Effects $
Medical  $
Tender/ Outboard  $

Notes:

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