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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
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FACILITY - COVERED OUTDOOR
FACILITY - FENCED OUTDOOR
FACILITY - INDOOR GARAGED
HURRICANE BLDG - DRYSTACK
HURRICANE BLDG - SELF PARK
MARINA - BERTH
MARINA - BUOY
MARINA - EASY DOCK
MARINA - HOIST
MARINA - INDOOR DRYSTACK
MARINA - INDOOR SELF PARK
MARINA - ON TRAILER
OWN BUSINESS - WAREHOUSE
OWN BUSINESS - YARD
RESIDENCE - BOAT HOUSE
RESIDENCE - CARPORT
RESIDENCE - GARAGED
RESIDENCE - HOIST
RESIDENCE - PRIV. DOCK
RESIDENCE - SIDE YARD
UNDETERMINED
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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 ($)
Liability amount ($)
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$25,000
$50,000
$100,000
$300,000
$500,000
Deductible
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$500
$1,000
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)
How did you hear about Boater's Insurance?
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