Personal Information
First Name:	Last Name:
Name of Boat:	Name Boat Titled In:
Occupation:	E-mail Address:
DOB:
Mailing address:
City:	State:	Zip:
Work Phone:	Home Phone:

Tell Us About Your Yacht:
Year Built:	LOA:	Manufacturer:	Type or Model:	Hull Mat.:

Machinery:
Year Built:	HP:	Manufacturer:	No. of Hours:	Type: Inboard Inboard/Outboard Outboard	Single Twin	Fuel: Gas Diesel

Equipment:
Fixed Auto System	VHF	Fathom	Fume Detector	GPS	Loran	Radar

Other Equipment:

Mooring:
Location:

Navigation:
Waters to be Navigated:

Pleasure Charter Commercial

Your Experience:
Operator Yrs:	Prior Vessels Operated:
Ownership Yrs:	Prior Vessels Owned:

Power Squadron Coast Guard Captain's License

Losses(in past five years):
Company:	Date:	Amount:
Cause:

General:
Current Insurance Co.:	Renewal Date:

Amount of Insurance Requested:
Vessel Amount:	Deductible:
Liability (P & I): 300,000 500,000 1,000,000	Medical Payments:

Additional Comments:

By submitting the above information, you certify that you have read the application and all information is true. It will also signify that you understand any concealment or misrepresentation of any material fact could affect this insurance coverage.

This insurance is subject to final underwriting approval by the carrier.