BOAT WORKSHEET

 

First Name:

Last Name:

Garaging Address:

Garaging City:

Garaging State:

California

Garaging Zip Code:

Phone Number:

Fax Number:

E-Mail Address:

MAILING ADDRESS (OPTIONAL)

 

Mailing Address
If Different from Garaging:

 

Mailing City:

Mailing State:

Mailing Zip Code:

DRIVER INFORMATION

 

 

Driver One

Driver Two

Driver Three

Driver Four

First Name

Birthdate

Sex

Marital Status

State Licensed

Yrs Boating
Experience

Occupation

BOAT INFORMATION

 

 

Boat

Trailer

Motor

Year

Make

Model

Type

Identification
Serial Number

Cost New Value

Hours Used
Each Year

Horsepower or
Motor Size

h.p.

Boat Length

ft.

Ownership

VIOLATION INFORMATION

 

Last 3 Yrs (Minors)
Last 5 Yrs (Majors)

Driver 1

Driver 2

Driver 3

Driver 4

Minor Violations - Speeding,
Turn, Stop Sign, Red Light, etc.

Accidents - Non Chargeable

Accidents - Chargeable

Major Violations - Drunk Driving,
Reckless, Hit & Run, etc.

COVERAGE INFORMATION

 

 

Bodily Injury

Property Damage

Personal Liability

Uninsured Motorist

Medical Payment:

 

DEDUCTIBLE INFORMATION

 

 

Boat & Motor

Trailer

Comprehensive (Theft)

Collision

MISC INFORMATION

 

Does the Boat have a Fire System?

 

 

Any Commercial Useage?

 

Fuel Type:

 

List Electronic Aids in the Boat:

Current Insurance Company:

Expiration Date:

Current Premium $:

Questions or Comments
to help the Agent:

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Then wait for online confirmation of your request.
Thank you for your interest.