Name Address
City State Zip
E-mail
Address
_
Operator
Information
Operator
Name
DOB or Age Years of Boating
Experience
0
1 2 3 4 5 6 7 8 9 10+
Years Owned
0
1 2 3 4 5 6 7 8 9 10+
If you haven't
taken delivery yet, when is your expected delivery
date?
Boating
Courses List other vessels
owned (Give year,
length, manufacturer, model, and number of years
owned)
_
Watercraft
/ Engine / Trailer Information
_
Boat
Year Length
Manufacturer /
Model
_
Engine(s)
_
Trailer
_
Equipment
_
Tender
Engine
Type Horsepower
Purchase
Date Price Current
Value
Boat Equipment
_
Navigation
Mooring /
Storage Location (Address) (Required for correct
rating) Miles Offshore
_
Values
& Rating Information
Purchase Price Date of Mkt Value Trailer Value
Liability Coverage
Medical Payments (Per Person Per Accident)
Personal Property
Use of Watercraft
select one
private_pleasure
charter
other
Have you or this watercraft been involved in any
accident, injury, or loss in the last 3 years?
If yes;
explain (Date of
loss, description of loss, amount of loss)
Current Insurance
Company Expiration Date
©Copyright
Voyager Insurance Services, Inc. All Rights Reserved.
1999
