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YOUR PERSONAL DATA:

Your Name:
Street Address:
City:
*State:
Zip/Postal:
*E-Mail
Re enter your E-Mail
Phone:
Fax (optional):
Marital Status:		Yes No
Homeowner?		Yes No
ATV Currently Insured?		(If yes, list carrier, and # of years continuous. If none, type N/C)

OPERATOR INFORMATION #1 (if none, leave blank)

Be specific to tell if accidents are "at-fault" or "NOT-at-fault" -(carriers require proof on NOT-at-fault accidents); Also, be specific as to TYPE of violations in fields below:

Name:
Sex:
Cycle Safety Course:
Number & Type of Accidents within last 3 years:
Number & Type of Major violations within last 3 years:

Birthdate:
Years U.S. Auto License:
Number of Years Boating Experience:

OPERATOR INFORMATION #2 (if none, leave blank)

Be specific to tell if accidents are "at-fault" or "NOT-at-fault" -(carriers require proof on NOT-at-fault accidents); Also, be specific as to TYPE of violations in fields below:

Name:
Sex:
Cycle Safety Course:
Number & Type of Accidents within last 3 years:
Number & Type of Major violations within last 3 years:

Birthdate:
Years U.S. Auto License:
Number of Years Boating Experience:

VESSEL & UNDERWRITING INFORMATION

Year of Boat::
VIN # (If available)::
Max, Speed (in MPH)::
Engine Make:
Outboard Motor Serial # (If available):
Engine Horse Power
Trailer Cov. Needed?
Trailer Value: ($)
Describe waters boat taken on?

Make & Model: (be specific):
ATV Type
Market Value: ($)
Engine HP:
.Fuel Type: (Gas, Diesel, etc.)
Year/Make/Model of Trailer:
Address/Marina Where is boat moored/stored?
Describe boat general usage? (fishing, ski, etc.)

VESSEL COVERAGES:

Limits of Liability:

$15/30 BI/10 PD

$25/50 BI/15 PD

$50/100 BI/ 50 PD

$100/300 BI/50 PD

$250/500 BI/ 100 PO

Hull Coverage :

NO Coverage

$250 Deductible

$500 Deductible

$1000 Deductible

Uninsured Motorists Coverage?

Yes No

Comments or Remarks:
(List additional drivers, special coverages, etc. here)

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Regular Mail

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