Insured's Name		Address
Date of Birth		Captain's License
Yr/Make/Model/Length		Hull Material	Aluminum Steel Fiberglass Wood Other
Date Purchased		# of engines (type and HP)
Max / Cruise Speed		Last Survey Performed
Yacht equipped with	GPS Radar Built-In CO2 Laser Plot Ship Shore Radio	EPIRB Depth Sounder Vapor Detector Burglar Alarm
Boat Experience (vessels owned/size/# of years owned )		Waters Navigated
Use of Yacht	Pleasure Business Charter Commercial Racing Other	Commercial Towing	$800 $1,000 $5,000 $10,000 Other
Hull Value		Deductible
Personal Property Limit		Hull ID (if known)
Please list all previous losses		Name & Location of Marina/Residence: Summer/Winter/Lay-up
Optional Coverage	Hurrican Haul Out Reimbursement Electronic Deductible Endorsement Blanket Fishing Equipment	Dinghy ( if over 16' or 25HP ) Year/Make/Model/Length/ Motor:Year/S-N/HP Trailer: Year/make/model/vaule
Phone Number		Email Address