BOAT: Personal Information - Primary Policyholder:
First Name:
Last Name:
Date of Birth:
Drivers License Number:
Years Licensed:
SSN:
Marital Status:
Gender:
Male
Female
Address:
City:
State:
Zip Code:
The best way to contact me is:
E-mail address:
Phone Number:
Fax number:
Vessel Information:
Year:
Mfg:
Model:
Length:
Date Purchased:
Purchase Price:
Hull Construction:
Fiberglass Wood Metal
# of Motors:
HP of Each Motor:
Motor Type:
Inboard Inboard/OutBoard OutBoard
Equipment:
Halon/CO2 Auto System Bilge Blowers Ship To Shore Radio Radar Depth Finder Electronic Alarm Propeller/Hub Locks GPS System Trailer Hitch/Axel Locks
Compass Fire Extinguisher(s) Loran RDF EPIRB Smoke Detector OB/Outdrive Locks Fume Detector Chart Plotter
Primary Waters of Navigation:
Other Waters:
Home Port Location:
Will vessel be used for water-skiing?
Yes
No
Lay-Up Dates:
Ashore
In Water
Will vessel be used for anything other than private pleasure?
If yes, describe other usage:
Private Boats Owned and/or operated (include length):
# of years operating any type of vessel:
Boating Education:
PS:
CGA:
YC:
Other:
Paid Captain/Crew? Yes No Is this vessel held for sale by this applicant? Yes No
Any watercraft losses last (3) years?
If yes, describe (include pay-out):
Ever been declined, nonrenewed or cancelled?
If so, why?
Is this vessel held for sale by this applicant?
If vessel is over 10 yrs old, do you have a survey?
If yes, date of survey:
Current Insurance Information:
Current Insurance Company:
Current Monthly Premium:
Current Policy Expiration:
MVR (if not clean) Date/Description:
Limits of Insurance:
Watercraft & Equipment - Deductibles: 2% (Min. $250) 5% (Min. $500)
Watercraft Liability: ($10,000 - $25,000 - $50,000 - $100,000 - 300,00 Or $500,000)
Watersports Liability: (If requested - must match watercraft liability)
Medical Payments (Max. $5,000):
Uninsured Boaters: ($10,000 - $25,000 - $50,000 - $100,000 - 300,00 Or $500,000)
Dinghy/Tenders and its Outboard Motor:
Personal Effects (Max. $5,000):
Trailer:
Emergency Waterway Services:
© 2005 Folks Insurance Group
Tel: 631.589.5100 | Fax: 631.589.3335 | 100 South Main Street | Sayville, NY 11782
