Name:
Address:
City:
State: MDVAPAWV
Zip:
Email:
Phone:
Fax:
Contact Me Via: Phone Fax Email Postal Mail
Do You Currently Own a Boat ? YES NO
Current Boat Insurance Carrier:
Boat is Registered in: MD PAWVOther
Inboard/Outboard Boat ? InboardInboard/OutboardOutboard
Length of Boat (ft):
Horsepower of Boat:
Maximum Speed of Boat:
Primary Territory of Boat: Inland WaterAtlantic CoastGreat Lakes
Total Value of Boat/Trailer/Motor:
Year Boat was Manufactured:
Desired Liability Limit on Your Boat: $100,000 $300,000 $500,000
Policy Deductible: $100 $250 $500
Any claims in the past 5 years? If so, please descibe the type of claim (Include date of loss and amount paid):
