Name:

Address:

City:

Zip:

Phone:

Email:

Date of Birth:

Coverage Information:

Liability:

25,000 50,000 75,000 100,000 200,000 300,000 500,000

Medical Payments:

1,000 2,000 5,000 10,000

Physical DMG Deductible:

50 100 250 500 1000 2500

Trailer Damage Deductible:

50 100 250 500 1000 2500                                                         

Territory Information:

Territories

 INLAND TERRITORY - Boats used primarily on the inland lakes and rivers in the state of Georgia

COASTAL TERRITORY - Boats having 10% more of the annual usage in the following bodies of water: Pacific Ocean, Atlantic Ocean, Arctic Ocean, Gulf of Mexico, Great Lakes,  St. Lawrence River, Hudson River, Chesapeake Bay., Delaware River.  The  above bodies of water are coastal waters and tributaries of the Continental United States of America, Hawaii and Canada.  "Coastal Waters" are considered to be that portion of the water which extends from the coastline a distance of 100 nautical miles out to sea. 

INLAND TERRITORY - Boats used primarily on the inland lakes and rivers in the states of Alabama, Florida, North Carolina, South Carolina, and Tennessee.

 INLAND TERRITORY - Boats used primarily on the inland lakes and rivers of any other State or Canada. 

Territory Information:

Boat Make:
           

Boat Year:

Boat Value:

Actual Cash Value

* For outboard powered boats do not include value of motor(s) - the outboard motor is a separate component (see next section down) .

Hull Material

Fiberglass
Wood
Other  

Boat Manufacturer's Name: 

Boat Length:

feet

Class:

Runabout or Cuddy: 
Type of Power >>> outboard or none inboard/outboard inboard jet drive

Cabin Cruiser:
Type of Power >>> outboard inboard inboard/outboard jet drive

Canoe, Dinghies, Row Boat: Type of Power >>> all

Sailboat:
Type of Power >>> Any type None

Catamaran:
Type of Power >>> Any type None

Houseboat:
Type of Power >>> Outboard or None Inboard

Pontoon:
Type of Power >>> Outboard

Operator:

Years of Experience for Primary Operator:

Operator under age of 21 on Policy

Yes No

Trailer Coverage:

Trailer Make:

Trailer Year:

Trailer Value: