Name

First Name

Last Name

Date Of Birth

YYYY

Mailing Address

Residence Status

How long have you lived at your current address?

Marital Status

Policy Effective Date

YYYY

Year

Make

Model

Hull ID

Registration Number

The TX # on your Boat

Length

Hull Material

Number of Engines

Horsepower

Propulsion Type

Motor Make

Motor Year

Engine/outdrive modified to enhance performance:

Top Speed

Year Boat Was Purchased

Mooring Place Street

Mooring Place City

Mooring Place Zip

Are you the original owner?

Watercraft Market Value

Value of Onboard Electronics- Graphs

Fishing Equipment Value

Rods, Reels, Tackle, Etc

Trailer Value

Boat/PWC kept at residence in season:

Select location at your place of residence:

Boat/PWC Use:

Multi-Owner?

Lienholder

Lender on Boat? Need name and address - put NONE if N/A

Additional Interest?

need name and address- put NONE if N/A

Years of Boating Experience

Total number of years driver has been boating in any jurisdiction, including international experience.

Drivers License State and Number

Household Members - Name- DOB- DL#

List all members of the household including DL and DOB - put None if no others

Have you taken an approved Safety Course?

Has the Named Insured had Boat liability insurance in the last 12 months?

Prior Boat Insurance Carrier

Put none if new purchase

Prior Policy Term Expiration Date

YYYY

Bodily Injury and Property Damage Limit

Liability Coverage

Deductible

Personal Effects

Coverage for the insured's personal items that are normally used in conjunction with the insured vehicle. Provides coverage up to the specified limit. A $250 deductible will apply.