Name
*
First Name
Last Name
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
*
(###)
###
####
Fax
(###)
###
####
Email
*
Preferred Response Method
Watercraft Type
User 1: Name
First Name
Last Name
User 1: Date of Birth
MM
DD
YYYY
User 1: Drivers License #
User 1: License State of Issue
User 1: Years Watercraft Experience
User 1: Minor Violations Last 3 Years
List Month/Year for each incident (mm/yyyy)
User 1: Major Violations Last 3 Years
List Month/Year for each incident (mm/yyyy)
User 1: At-Fault Accidents Last 3 Years:
List Month/Year for each incident (mm/yyyy)
User 2: Name
First Name
Last Name
User 2: Date of Birth
MM
DD
YYYY
User 2: Drivers License #
User 2: License State of Issue
User 2: Years Watercraft Experience
User 2: Minor Violations Last 3 Years
List Month/Year for each incident (mm/yyyy)
User 2: Major Violations Last 3 Years
List Month/Year for each incident (mm/yyyy)
User 2: At-Fault Accidents Last 3 Years
List Month/Year for each incident (mm/yyyy)
User 3: Name
First Name
Last Name
User 3: Date of Birth
MM
DD
YYYY
User 3: Drivers License #
User 3: License State of Issue
User 3: Years Watercraft Experience
User 3: Minor Violations Last 3 Years
List Month/Year for each incident (mm/yyyy)
User 3: Major Violations Last 3 Years
List Month/Year for each incident (mm/yyyy)
User 3: At-Fault Accidents Last 3 Years
List Month/Year for each incident (mm/yyyy)
User 4: Name
First Name
Last Name
User 4: Date of Birth
MM
DD
YYYY
User 4: Drivers License
User 4: License State of Issue
User 4: Years Watercraft Experience
User 4: Minor Violations Last 3 Years
List Month/Year for each incident (mm/yyyy)
User 4: Major Violations Last 3 Years
List Month/Year for each incident (mm/yyyy)
User 4: At-Fault Accidents Last 3 Years
Year
Make
Model
Serial #
New or Used
1, 2 or 3 Passenger:
(JetSkis)
State of Navigation
Purchase Date
MM
DD
YYYY
Purchase Price
Describe any permanently installed or custom equipment
Motor 1: Year
Motor 1: Make
Motor 1: Serial #
Motor 1: HP
Motor 2: Year
Motor 2: Make
Motor 2: Serial #
Motor 2: HP
Miscellaneous Equipment
Item Description, $ Value, Item Description, $ Value, ...
Personal Effects
Item Description, $ Value, Item Description, $ Value, ...
Boat Type
Select
Outboard
Inboard
Inboard/Outboard
Jet Powered
Sailboat
Houseboat
Pontoon
Boat Construction
Select
Fiberglass
Wood
Metal
Aluminum
Steal
Other Construction Material if not listed above
Area of Navigation
Garaging/Mooring During Period of Use
Select
Driveway/Yard/Garage
Private Storage
Apt/Townhouse Lot
Mobile Home Park
Marina
Slip
Other
Garaging/Mooring During Lay Up:
Select
Driveway/Yard/Garage
Private Storage
Apt/Townhouse
Mobile Home Park
Marina
Slip
Other
Loss 1: Date
MM
DD
YYYY
Loss 1: Cause of Loss
Loss 1: Describe damage to watercraft and equipment
Loss 1: Was anyone injured?
Please explain
Loss 1: $ Amount of Damage
Loss 2: Date
MM
DD
YYYY
Loss 2: Cause of Loss
Loss 2: Describe damage to watercraft and equipment
Loss 2: Was anyone injured?
Please explain
Loss 2: $ Amount of Damage
Loss 3: Date
MM
DD
YYYY
Loss 3: Cause of Loss
Loss 3: Describe damage to watercraft and equipment
Loss 3: Was anyone injured?
Please explain
Loss 3: $ Amount of Damage
In what state is the boat primarily navigated?
How many years has the principal operator maintained and operated a watercraft?
Has engine been turbocharged, supercharged, altered or modified in any way for the purpose of enhancing speed or performance?
Is this boat the primary residence of the insured?
Is craft permanently moored?
If yes, Where (Including Zip Code)
Is this boat currently for sale by the insured?
Has the principal operator of the boat completed either the US Coast Guard Auxiliary or US Power Squadron introductory courses?
Is your motor's propeller construction other than stainless steel?
Is personal watercraft currently held for sale and if so, how long has it been for sale?
Where will personal watercraft be stored when not in use?
(Including Zip Code)
Comments/Questions
