Named Insured:    Effective Date:

Address:   

 City:    State:    Zip:

Date of Birth:    Gender: Select M F    Marital Status: Select Single Married

SS#:    Driver's License #:

Email:    Phone:

Safety Course Discount: Select Yes No (Yes requires copy of certificate)

Boat Year:    Make:    Model:

Boat Type:    Motor Type:

Verify Boat Length:    Engine Horsepower:    Engine (single/twin): Select Single Twin

Trailer (if applicable): Year    Make:    Model:

What zip code is the boat operated, moored, or stored in (if different from Named Insured Address):

Available Coverages

Limits of Liability incl/Pollution (split limits available): Select $25k $50k $100k $300k $500k    Medical Pay: Select $1,000 $2,000 $5,000 $7,500 $10,000    

UB/UIB (split limits available): Select $10k $25k $50k $100k     Fishing Equipment: Select $1,000 $2,500 $5,000 $10,000   

 Personal Effects (split limits available): Select $1,000 $2,000 $3,000 $4,000 w/boat lift w/boat lift    On-Water Towing: Select $100 $250 $500 $1,000 $2,500

Additional Notes:

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