Boat Insurance Form

Applicant Information:

Referred by Customer ID #

First Name:

Last Name:

Date of Birth:

Address:

City:

State:

Zip:

Phone:

Email:

# of years of boating experience::

Approved Safety Course Completion?:

Marital Status:

Residence Type:

Vessel Information:

Year:

Make:

Model:

Length:

Value ($):

Maximum Speed (MPH):

Horsepower:

Hull Type:

Hull ID #:

Engine 1 Information:

Year:

Make:

Model:

Engine Type:

Engine Value ($):

+ add one more engine

Trailer Information:

Year:

Make:

Model:

Value ($):

Coverage Information:

Liability: BI Per Person/BI Per Accident/Property Damage:

Uninsured Motorist Bodily Injury:

Medical Payments:

Additional Driver +1:

First Name:

Last Name:

Date of Birth:

Marital Status:

# of years of boating experience:

Approved Safety Course Completion?:

+ add one more driver

Tickets or Accidents:

Please list any additional coverages desired:

Please note that by submitting your information using this online form that no coverage is bound at time of submission.

  • We assure you that any and all information will not be distributed to 3rd parties other than for under writing verification.
  • Many factors are used for calculating accurate rates from information provided by you and other sources including up to but not limited to driving history, claims submitted, previous insurance, and household members.
  • When submitting this form, you agree to relieve us from any liability in the event your information is viewed by others.