Premier Insurance Agency - Boat Insurance Form New

Trailer?:

Main Operator First Name:

Main Operator Last Name:

Address:

City:

State:

Zip Code:

Phone Number:

Alternate Phone Number:

E-mail Address:

Do you rent or own your home?:

Have you moved in the last 60 days?:

Gender

Marital Status

Do you have a checking account?:

Number of operators to insure (including yourself):

List boats main operator and any additional operator’s age, name and whether operator has completed Coast Guard Auxiliary/Powered Squadron Course:

Is the boat currently insured?:

Current Policy Expiration:

Current/Desired Policy Deductible:

Boat Type:

Use:

Vessel Storage Location:

Waters Navigated:

Personal Property Insurance:

Used for racing?:

Hull Make/Model:

Type:

Length:

Estimated Market Value:

Year Built:

Max Speed in MPH:

Personal Effects:

Misc. Boating Equipment:

Trailer?:

If Yes, Make and Value:

Engine 1 Make:

Engine 1 Year:

Engine 1 Type:

Fuel 1 Type:

Est. Value 1 (O/B Only):

Horse Power 1:

Engine 2 Make:

Engine 2 Year:

Engine 2 Type:

Fuel 2 Type:

Est. Value 2 (O/B Only):

Horse Power 2:

Liability:

Medical Payments:

Water Ski Medical Needed?:

Any listed operators involved in boating accident within the past 5 years; boat and/or equipment suffered damage within past 5 years; or any listed operator involved in auto accident or received moving traffic citation in last 3 years?:

If yes, please describe:

Check this box to grant our agency permission to secure your credit and/or claim history, for insurance purposes only, under the Fair Credit Reporting Act.

How would you describe your credit rating?: