Boat Account Information Date MM slash DD slash YYYY Prepared By:*Alonso, FrancescaBalco, CraigBardach, DavidCarrizo, LissethD’Hondt, MichaelDugan, LeeAnnHilliard, SherrinKontodiakos, MichaelLamb, KaylaLamb, ShelbyLevi, DouglasLuciano, CarmenMella, TonyWeaver, CassidiYoung, AmyBright, SherriClient Name: How did you hear about our office? Phone:Email Address:* Preferred Method of Contact Phone Email Text Address: Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Do You: Own Rent Current Insurance Carrier: Renewal Date: MM slash DD slash YYYY Years With: Premium $: Other than price what is most important to you? Or Between Price, Protection & Svc what is most important? Driver InformationDOB MM slash DD slash YYYY Marital Status: Female Male Driver's License #: State: Years Boat Experience Tickets, accidents, suspensions, or claims w/ the last 5 years? Yes No DetailsDriver 2 (If Necessary)Name: DOB MM slash DD slash YYYY Female Male Relation: Marital Status: Driver's License #: State: Tickets, accidents, suspensions, or claims w/ the last 5 years? Yes No DetailsOthers in the household of driving age? Boat InformationYear: Make: Model: Market Value Type Inboard Outboard Both Jet Hull Material Number of motors Total Horsepower Max Speed Coverage for trailer Use Pleasure Business Where is it Storage Boat / Jetski InformationYear: Make: Model: Market Value Type Inboard Outboard Both Jet Hull Material Number of motors Total Horsepower Max Speed Coverage for trailer Use Pleasure Business Where is it Storage One Way Miles: Days/Week: Annual Miles: Current / Desired Limits... (Or Copy of Current Declarations Page)BI: PD: Comp: Coll: UM: Med Pay: On water towing: Fishing Equipment ($): CommentsThis field is for validation purposes and should be left unchanged.
