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| Preparer's / Referrer's Information |
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Who Are You* |
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How Were You Referred To Us* |
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Your Name (Include Agency or Business Name if applicable)*
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Your Phone Number*
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Your Email Address*
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Your Fax Number* |
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Source of Submission |
WEB |
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General Information About Insured |
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Full Name of Vessel Owner* |
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Date of Birth* |
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Street Address* |
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City* |
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State* |
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Zip Code*
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Phone Number |
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Email Address |
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Years as Boat Operator |
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Years as Boat Owner |
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Safety Course Completed
(A copy of your certificate is required) |
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Occupation |
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Driver's License Number |
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MVR Driving Record
Last 5 Years |
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Social Security Number
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Marital Status
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HomeOwner Status
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Previous Vessels Owned or Operated |
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Ownership Status:
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Length and Make |
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Years Operated |
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Length and Make |
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Years Operated |
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Length and Make |
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Years Operated |
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Length and Make |
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Years Operated |
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Boat Losses/Claims
(If Any: please
explain. Include
Date and Amount) |
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Vessel / Engines / Storage / Usage Information (For Vessel To Be Quoted)
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Purchase Date |
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Purchase Price
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Please list Bank/Lienholder
Name and Address
(if applicable) |
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If Vessel Is Currently Insured,
List Carrier Name and Expiration Date
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Vessel Year* |
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Manufacturer* |
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Vessel Model Number* |
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Vessel Type* |
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Vessel Length* |
Feet Inches |
Vessel Weight (for High Performance boats) |
lbs. |
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Hull Type |
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Hull Material |
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Hull ID Number |
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Engine(s) year |
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Engine(s) Manufacturer* |
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Number of engines* |
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Engine Horsepower EACH* |
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Engine Type* |
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Fuel Type |
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Engine Serial Numbers |
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Trailer Year |
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Trailer Manufacturer |
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Trailer Serial Number |
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Vessel Top
Capable Speed (mph) |
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General Navigation Area |
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Intended Use |
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In Season Vessel Address
(City, State, Zip Code, County) |
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In Season Vessel Location |
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Out Of Season Vessel Address
(City, State, Zip Code, County) |
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Out Of Season Layup Location |
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Layup Start Date
(if applicable) |
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Layup End Date
(if applicable) |
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Layup Method |
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Safety / Anti-Theft Equipment (credits may apply for each item checked)
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Compass |
Auto-fire system |
GPS |
Fume detector |
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Depth Finder |
Outdrive Locks |
Radar |
CO2 detector |
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VHF Radio |
Prop locks |
EPIRB |
Smoke alarm |
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Anti-theft alarm |
Trailer locks |
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Coverage / Limits Requested (standard limits may apply)
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Coverage Type Requested:
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Boat and Engine(s) Value $*
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Trailer Value $
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Liability Limit $
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Deductible amount $
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Personal Property $
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Dinghy / Tender value $
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Towing $
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Medical payments limit $
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Uninsured Boater limit $
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Other Coverage
Requests
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Additional Comments
Please add any additional information below and/or explain any "OTHER" responses you gave.
If you would like an additional vessel quoted, please specify it's Year, Make, Model, Engine(s) HP, and Total Value.
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