Please enable JavaScript in your browser to complete this form.DateVessel NameContact NameName of InsuredIs the Insured anIndividualPartnershipDBACorporationHome PhoneBusiness Phone *Fax Number Cell NumberEmail *Web AddressMailing AddressHow Did You Hear About Us?# of Years in BusinessPresent InsurerExpiration DateVessel Use:If Comm. Fishing, Type?HomeportIs vessel docked or moored?Lay-Up Period (if any)ThruVessel Informationa) Year Builtb) Lenghtc) Maked) Modele) Gross Tonsf) Hull Materialg) Official #h) Trailer DescriptionENGINE INFOYear BuiltGasolineInboardOutboardI/O# of Engines1) YearMakeModelH/P2) YearMakeModel H/P3) YearMakeModel H/P(6 Packs Only) Is Vessel Equipped with the Following?a) High Water Level AlarmsYesNob) Engine AlarmsYesNoc) Anti Theft/AlarmYesNod) EPIRB)YesNoe) Fixed Fire Extinguishing SystemYesNof) Fumes DetectorYesNoWaters NavigatedLien HolderAmountAddress/PhoneDate of Last SurveyBy Whom?Coveragesa) Hull/Machinery LimitTrailer ValueDeductiblesb) P&I Limitc) Max # of Passengersd) Avg # of PassengersCaptain(s)Information: Is Vessel Owner OperatedYesNoIs a Licensed Capt. Always in Control?YesNo1) NameDOBYrs. ExpLicense2) NameDOBYrs. ExpLicense3) NameDOBYrs. Exp LicenseDoes Insured Own Other Vessels?5 Year Loss History (on any owned vessels): If yes, pleaselist Date, Type, Status and amount Paid5 Year Loss History (on any owned vessels): If yes, pleaselist Date, Type, Status and amount Paid (copy)5 Year Loss History (on any owned vessels): If yes, pleaselist Date, Type, Status and amount Paid (copy) (copy)Submit