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Owner Information
First Name
Middle Name
Last Name
Zip Code
Not a real zip code.
Street Address
City
State
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Colorado
Connecticut
Delaware
District Of Columbia
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Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Email
phone
Boat Information
Vessel type
House Boat
Boat builder
Boat model
Boat year (yyyy)
Boat length (ft)
Top speed (mph)
Select all of the equipment the boat has installed
Depth Finder
VHF Radio
GPS
Radar
SATNAV
CO-2
SSB
Auto HALON
Loran
Engine Information
Engine make
Number of engines
Horsepower per engine
Engine year (yyyy)
Engine type
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I/O
Outboard
Fuel type
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Gas
Diesel
Mooring Information
Mooring storage/location
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MARINA - BERTH
MARINA - BUOY
Marina Name
Zip
City
State
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Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Hurricane response plan (if the boat is stored within 20 miles of the Gulf or Atlantic Coast)
Experience
Date of birth (mm/dd/yyyy)
Occupation
Are You Homeowner?
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Yes
No
Marital Status
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Married
Single
Divorced
Separated
Widowed
Civil union
Years of boating experience
Years of boating ownership
Input the two most recent experiences
Years
Length
Description of Boat Operated
Owner
Operator
Years
Length
Description of Boat Operated
Owner
Operator
Boating safety classes
Coast Guard Aux
USPA
Other
USCG Licenses
6-Pak
100 Ton
Please list any auto driving tickets, accidents, or DUIs past 3 years.
Please list boating claims, losses or accidents past 5 years.
Boat Usage
Is the boat to be used for private pleasure only?
Yes
No
Is there a paid skipper / crew?
Yes
No
Will this boat be used for charter, rental, or leasing?
Yes
No
Will this boat be used as a residence or live aboard?
Yes
No
Do you have this boat currently for sale?
Yes
No
Is this boat currently insured?
Yes
No
Name of insurance company
Date insurance expires (mm/dd/yyyy)
Is this boat owned by a corporation or LLC?
Yes
No
If yes, provide legal name of corporation or LLC
Has this boat ever been damaged?
Yes
No
If yes, explain the damage
Has insurance ever been cancelled or refused?
Yes
No
If yes, explain why it was cancelled or refused
Do you have a current survey?
Yes
No
Date of latest survey (mm/dd/yyyy)
Select type of survey
Select type of survey
Hual Out
In Water
Upload survey
Coverage Request
Date of purchase (mm/dd/yyyy)
Total purchase amount ($)
Boat and motor current value ($)
Liability amount ($)
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$100,000
$300,000
$500,000
$1,000,000
If more than two (2) unrelated owners, please explain
Other comments (optional)
How did you hear about Boater's Insurance?
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Marine Surveyor
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