Mailing Address
If Different from Garaging:

	Driver One	Driver Two	Driver Three	Driver Four
First Name
Birthdate
Sex	Male Female	Male Female	Male Female	Male Female
Marital Status	Single Married Divorced Widowed Separated	Single Married Divorced Widowed Separated	Single Married Divorced Widowed Separated	Single Married Divorced Widowed Separated
State Licensed
Yrs Boating Experience
Occupation

	Boat	Trailer	Motor
Year
Make
Model
Type	Sail Boat Ski Boat Pontoon Boat House Boat Cabin Cruiser Bass Fishing Boat Flat Bottom Tunnel Hull Pickle Fork	Single Axle Dual Axle Three Axle	No Motor In-Board Out-Board In/Out-Board
Identification Serial Number
Cost New Value
Hours Used Each Year	Under 50 51-100 101-200 201-300 301-400 401-500 500+	Horsepower or Motor Size	h.p.
Boat Length	ft.	Ownership	Leased Paid-Off Financed

Last 3 Yrs (Minors) Last 5 Yrs (Majors)	Driver 1	Driver 2	Driver 3	Driver 4
Minor Violations - Speeding, Turn, Stop Sign, Red Light, etc.	None 1 2 3 4	None 1 2 3 4	None 1 2 3 4	None 1 2 3 4
Accidents - Non Chargeable	None 1 2 3 4	None 1 2 3 4	None 1 2 3 4	None 1 2 3 4
Accidents - Chargeable	None 1 2 3 4	None 1 2 3 4	None 1 2 3 4	None 1 2 3 4
Major Violations - Drunk Driving, Reckless, Hit & Run, etc.	None 1 2 3 4	None 1 2 3 4	None 1 2 3 4	None 1 2 3 4

	Bodily Injury	Property Damage
Personal Liability	15,000/30,000 25,000/50,000 50,000/100,000 100,000/300,000 250,000/500,000	5,000 10,000 25,000 50,000 100,000
Uninsured Motorist	None 15,000/30,000 25,000/50,000 50,000/100,000 100,000/300,000 250,000/500,000	None 3,500 Deductible Waiver
Medical Payment:	No Coverage 1,000 2,000 2,500 5,000 10,000 15,000 20,000 25,000 50,000 100,000

	Boat & Motor	Trailer
Comprehensive (Theft)	No Coverage 250 500 1,000 1,500 2,000	No Coverage 250 500 1,000 1,500 2,000
Collision	No Coverage 250 500 1,000 1,500 2,000	No Coverage 250 500 1,000 1,500 2,000

Current Insurance Company: