Name:
Street Address:
City:
County:
State:
Zip Code:
Home Phone:
Email:
Primary Operator:	Male Female
Marital Status:	Single Married Other
Date of Birth:	Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Years Experienced:
Are you a homeowner?	Yes No
Spouse/Second Operator's Name:	Male Female
Second Operator's Date of Birth:	Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Years Experienced:
Watercraft safety courses taken: None Primary Operator 2nd Operator
Watercraft association memberships:
Please list any MVR violations, accidents, injuries, or losses within the last 5 years.
Has the watercraft been insured within the past 30 days? Yes No
If yes, provide the name of the insurance company:
This policy expired/expires: Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Please provide the following watercraft information.
Maximum number of passengers for personal watercraft: 1 2 3 4
Watercraft type: Select Runabout Sport Boat Cruiser Bass Boat Sport Fisher Trawler Ski Boat Pontoon Boat Deck Boat Houseboat Motoryacht Jet Boat Jet Ski Sailboat (monohull) Sailboat (multihull)
Year: Manufacturer: Model:
Length: Hull material:
Number of engines: 1 2 Engine CC's: Type: Select Inboard Outboard In/Outboard Jetdrive
Total horsepower: Top Speed (mph):
Purchase date: Purchase price:
Homeport city and state:
Waters primarily navigated: Select Inland Lakes & Rivers Chesapeake Bay Puget Sound Great Lakes San Francisco Bay Atlantic Pacific Gulf of Mexico
Is watercraft stored within 10 miles of Coastal Waters for more than 30 days a year? Yes No
Please select the type of coverage you desire (see explanation of coverage for more info).
For Boats For Personal Watercrafts (Jet Skis) Hull coverage desired (value): Hull coverage: Deductible (select one): $250 $500 Deductible (select one): $250 $500 Liability limits (select one): Liability limits (select one): 50/50/50 50/100/50 100/100/100 15,000 CSL 25/50/10 50/100/25 Trailer value (if applicable): Waterski liability? Yes No Tender (dinghy) value (if applicable): Trailer Coverage? Yes No
Additional comments or concerns:
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