Name *

First Name

Last Name

Phone *

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth: *

MM

DD

YYYY

Marital Status *

Single

Married

When would the policy need to start? *

MM

DD

YYYY

Has the operator had any violations or accidents in the last 36 months? *

Yes

No

Has ANY operator had a paid marine loss in the past 3 years? *

Yes

No

Are you looking for liability only? *

Yes

No

What is the navigation area? *

Coastal - Anywhere in the U.S.

Coastal - up to 75 miles from Mooring/Storage Station

Inland -within Mooring/Storage state only

Inland - anywhere in the U.S.

What is the fuel type? *

Gas

Diesel

Electric

No electric/motor

What is the power type? *

Inboard

Inboard/Outdrive

Jet

No Engines

Outboard

Outboard/Jet Drive

Sail

Does the watercraft have any of the following protective devices? * Select all that apply

Alarm System (High water/Fire/Theft)

Central Station Monitoring System

NMMA Certification

Theft Recovery System

Automatic Fire Extinguishing Equipment

Dock Assist

No Strike Lighting System

Is there any existing damage to the watercraft? *

Yes

No

Will the watercraft be layed-up/stored out of the water for at least 3 months during the policy period? *

Yes

No

Is the watercraft used as a residence or for business purposes? *

Yes

No

Is the watercraft under construction, designed or modified for competition, or hauled on a trailer not specifically manufactured as a boat trailer? *

Yes

No

Does the applicant live within 150 miles of the watercraft mooring/storage location? *

Yes

No