URLThis field is for validation purposes and should be left unchanged.Personal InformationFull Name:(Required) First Last Date of Birth:(Required) MM slash DD slash YYYY Gender:(Required) Female Male Occupation:(Required)Marital Status:(Required) Single Married Divorced Widowed Spouse Full Name:(Required) First Last Spouse Date of Birth:(Required) MM slash DD slash YYYY Spouse Gender:(Required) Female Male Spouse Occupation:(Required)Is there a co-applicant?(Required) Yes No If so, please provide Full Name:(Required)Co-applicant occupation:(Required)Home Address:(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is the home address different than the mailing address?(Required) Yes No Mailing Address (if different)(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone(Required)Email(Required) Watercraft InformationYear:(Required)Make(Required)Model(Required)Hull ID Number (HIN)(Required)Does your watercraft have an officially registered name?(Required)List the registration number and country of registration(Required)Registration NumberCountry of RegistrationWho is the listed owner of the watercraft?(Required)Does your watercraft have any modifications?(Required) Yes No If so, please list the type, manufacturer, and model:(Required)Is there any additional equipment on/in your watercraft (bilge pumps, fume detector, depth sounder, radar)?(Required) Yes No If yes, please describe:(Required) Does your watercraft feature the following equipment: 1. Fire extinguishers?(Required) Yes No 2. Shore to shore radio?(Required) Yes No 3. Anti-theft devices?(Required) Yes No 4. Heating?(Required) Yes No Does your watercraft have a cooking stove?(Required) Yes No If so, how many and of what kind?(Required)Do you have any lifeboats/portables in your watercraft?(Required) Yes No If so, what kind?(Required)Does your watercraft have a trailer?(Required) Yes No a. What is the make, model, and year?(Required)b. What is the capacity (Ibs)?(Required)c. When was the trailer purcased?(Required)Does the watercraft have any sleeping facilities?(Required) Yes No If so, how many beds?(Required)If there is any existing damage to the watercraft, please describe:Length:(Required)Beam (width):(Required)Engine Type:(Required) Outboard Inboard Inboard/Outboard Jet Other Engine Manufacturer:(Required)Horsepower:(Required)Top Speed (mph):(Required)Fuel Type:(Required) Gasoline Diesel Electric Hull Type:(Required) Fiberglass Aluminum Wood Other Purchase Price:(Required)Current Market Value:(Required)Purchase Date:(Required)Is there a lienholder?(Required) Yes No If yes, provide lienholder name and address:(Required)NameAddressUse and StoragePrimary Use:(Required) Personal Commerical Charter Racing Other When was the date you last used this watercraft?(Required)Typical Body of Water:(Required)Operating Area (inland, coastal, international waters, etc.):(Required)Where is the watercraft stored when not in use?(Required)(Select all that apply) Marina Dry Dock Trailer Private Dock Other Other:(Required)Is the vessel kept in or transported through hurricane-Prone areas?(Required) Yes No If your watercraft has ever been out of service, how was it stored?Do you rent your watercraft to others?(Required) Yes No If so, in what frequency, for how long, and for what purpose typically?(Required)Is the watercraft used for business purposes?(Required) Yes No Please describe:(Required)Is the watercraft used for racing?(Required) Yes No If so, list the frequency and where the races occur(ed):(Required)Is the watercraft used for waterskiing?(Required) Yes No How often?(Required)Do you have a paid crew?(Required) Yes No Is this watercraft a primary residence?(Required) Yes No If yes, for how many people?(Required)Please list all operators, residents, and dependents of the watercraft:(Required)Full NameGenderMarital Status:DOB:Occupation:Auto Driver's License #:State(s) Licensed: Add RemoveOperator InformationList all regular operators:(Required)NameDOBLicense NumberExperience Add RemoveDoes the operator have a physical impairment that would affect their ability to drive?(Required) Yes No If yes, please describe:(Required)Is the operator undergoing treatment that would affect their ability to drive?(Required) Yes No If yes, please describe treatment:(Required)Has the operator had any licenses suspended or revoked in the last three years?(Required) Yes No If yes, please explain:(Required)Any boating safety courses completed?(Required) Yes No If yes, list courses and dates:(Required)Any previous watercraft insurance claims?(Required) Yes No If yes, provide dates and details:(Required)Any motor vehicle violations or accidents in the last 5 years?(Required) Yes No If yes, please explain:(Required)Insurance InformationDo you currently have (or previously had) watercraft insurance?(Required) Yes No If so, please list the carrier and policy number:(Required)Have you had coverage declined, cancelled, or non-renewed in the last three years?(Required) Yes No If yes, please explain:(Required)Have you had a foreclosure, repossession, bankruptcy, or filled for bankruptcy during the past five years?(Required) Yes No Have you had a judgement or lien during the past years?(Required) Yes No Has your insurance been transferred within your insurance agency?(Required) Yes No During the last five years, have you or your co-applicant been convicted of fraud, bribery, arson or any other arson-related crime?(Required) Yes No If yes, please explain:(Required)Has any operator listed had a motor vehicle or boating accident (regardless of fault) or been convicted of a moving violation within the last five years?(Required) Yes No If so, please list:(Required)Date of the occurrence:Location of the occurrence:Damage (describe):Bodily injury:Death: Add RemovePlease describe your loss history, whether it was paid by insurance or not:(Required)Coverage DetailsLiability Coverage Limit Requested:(Required)Hull Coverage:(Required) Agreed Value Actual Cash Value Deductible preference:(Required)Do you want coverage for the following?(Required) Towing & Assistance Personal Effects Fishing Equipment Trailer Coverage Uninsured Boater Coverage Medical Payment Pollution Liability Charter Liability (Check all that apply)Additional InformationUse the space below to provide any other relevant information or special considerations that may affect your life insurance policy: Δ
