Owner Information *First Name Middle Name *Last Name *Address *City *State *Zip *Email Address *Daytime Phone *Date of Birth *Courses taken ASA Safety at Sea USCGA USCG Licensed USPS US Sailing *Membership ASA USCGA USPS US Sailing None List previous boats owned Manufacturer: Length: # of Yrs Owned: Manufacturer: Length: # of Yrs Owned: *Loss History Choose One None 1 Claim < $5,000 1 Claim > $5,000 2 or More Claims *Years Boating Boat Information *Builder *Year Built *Purchase Price *LOA *Model Choose One Bow Rider Catamaran Convertible Cruiser Cuddy Cabin Express Houseboat Motor Yacht Mulit-Hull Open Other Performance Sail Boat Sport Fish Trawler Trimaran *Engine Make *Engine HP *Engine Single Twin *Hull Material Choose One Fiberglass Carbon Kevlar Wood Aluminum Other If Other: *Mast Construction Choose One Not applicable Carbon fiber Aluminum Fiberglass Other If Other: Most Recent Survey Date *Usage Choose One Private Pleasure Racing Charter Other If Other: Navigation Information Summer Location *State: *Zip: Winter Location *State: *Zip: Lay Up Dates (if applicable) Choose One 11/1 to 4/1 11/1 to 5/1 12/1 to 4/1 12/1 to 5/1 Other *Waters Navigated Crew Details *Do you have a captain or crew? Yes No Insurance Coverage Requested Coverage Amount of Insurance Requested *Hull Coverage (including equipment and electronics) $ Tender $ *Liability $ Choose One 300,000 500,000 1,000,000 Other If Other: Trailer $ Other $ Other Information *How did you hear about us?

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