Peter Laczko Insurance - Yacht and boats larger than 35 feet Form

YACHT AND BOATS LARGER THAN 35 FEET

Named Insured:

Beneficial Owner (If Corpately Titled, Or Other Than Named Insured):

Insured's Email:

example@example.com

Insured's Phone Number:

Previous Insurance:

Mailing Address:

Mooring Address:

Mooring Type:

VESSEL INFORMATION

Year:

Manufacturer:

Model:

Length:

Hull Material:

Top Speed:

Date Purchased:

Purchase Price:

Number Of Engines:

Engine Year:

Manufacturer:

Total HP:

Engine Type:

Fuel Type:

Safety:

Radar

GPS

Depth Sounder

Halon

GPS Theft Tracking:

Live Aboard

Do you have insurance now on a different boat

USE:

Live Aboard:

Boating Course

Captains License

Date First Licensed

Date

PRIOR LOSS DETAILS (DATE, DESCRIPTION, AMT PAID)

Trailer Year:

Manufacturer:

Value:

Navigation Limit:

PRIMARY OPERATOR INFORMATION:

Name:

DOB:

MonthDayYear

Driver's State:

Boating Course:

Captain's License:

Date First Licensed:

HomeOwner:

Marital Status:

COVERAGE INFORMATION:

Currently Insured:

Current Hull Value:

Deductible:

Liability:

Towing:

Personal Effects Amount:

Lien Holder: