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Name: E-mail: Phone: City: ST: Zip: County: Date of Birth: Total Years Boating Experience Any boat losses or more than 2 auto violations in the last 5 years? If yes, please explain Boat Information Waters boat will be used in: Fresh Salt Both Year: Make: Model: Length: ft inches Engine Type: Outboard Inboard Inboard/Outboard Jet Number of Engines: Horsepower: Hull Material Aluminum Fiberglass Other Dollar values (not including taxes) Hull Outboard Engine Trailer Total with accessories Credits New Boat: Safety Course Coverages (the defaults are standard) Deductible: $100 $250 $500 Liability Limit: $50,000 $100,000 $300,000 $500,000 Personal Effects: Medical Payments / Uninsured Boater: Within Liability Limits Not in Liability Limits Premium Payment Options: 25% down with up to 9 payments 50% down - balance in 30 days Paid in Full