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Owner Information

First Name

Middle Name

Last Name

Street Address

Zip Code

City

State

phone

Fax (optional)

PWC Information

PWC #1

PWC year(yyyy)

Length (ft)

Current value ($)

Manufacturer

PWC Model

CCs or HP

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Trailer Information

Do you have any trailer(s)? Yes No

Trailer #1

Trailer year (yyyy)

Trailer make

Current value ($)

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Mooring Information

Mooring storage/location

Zip

City

State

If PWC not garaged at home, how is the unit protected from theft?

Hurricane response plan (if the boat is stored within 20 miles of the Gulf or Atlantic Coast)

Experience

Date of birth (yyyy/mm/dd)

Occupation

Years of PWC/boating experience

Years of PWC/boat ownership

Previous PWC/boat owned

PWC/boating safety classes Coast Guard Aux USPA Other

Please list any auto driving tickets, accidents, or DUIs past 3 years.

Please list PWC/boating claims, losses or accidents past 5 years.

PWC Usage

Will any of the PWC operators be under the age of 16? Yes No

Will this PWC be used for charter, rental, or leasing? Yes No

Do you have this PWC currently for sale? Yes No

Is this PWC currently insured? Yes No

Name of insurance company

Date insurance expires (mm/dd/yyyy)

Is this PWC owned by a corporation? Yes No

If yes, provide legal name of corporation

Has this PWC 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

Coverage Request

Date of purchase (yyyy/mm/dd)

Total purchase amount ($)

Liability amount ($)

Deductible

Note: Deductibles and Liability Limit will be quoted at closest amount available to amount selected

If more than two (2) unrelated owners, please explain

Other comments (optional)

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809 Podva Road, Danville, CA 94526

800-344-7488

info@bia.us

CA Licences.#0774116