First Name
Last Name
Address
City
State
Zip
Date of Birth
Phone
Email
Drivers License #
Drivers License State
Boating Courses
Power Squadron Training
Coast Guard Auxiliary
Other Experience:

Mooring Information - Home Port
Marina Name
City
Address
State
Country
Mooring Information - Hurricane
Marina Name
City
Address
State
Vessel Name
Type of Vessel
Hull Material
Hull Manufacturer
Year of the Boat
Years of Boating Experience
Length (In Feet)
Use of Boat
Stored on a Trailer ?
  Yes   No
HP of Engine
  Gas   Diesel
Engine Manufacturer
Year Engine Built
Maximum Boat Speed (In Knots)
Country Registration  Documentation # 
Purchase Price  Purchase Date 

Navigation Aids: VHF Radio
Sat Nav
Radar
GPS
Compass
Depth Finder
Auto Pilot
Safety Equipment: RDF
Engine Alarm
Fume Detector
Theft Alarm
Auto Fire Extinguisher
Other Nav/Safefy:

Previous Boats Owned
Yrs Owned Manufacturer Type Waters Navigated

Hull Value

Deductible

Protection and Indemnity (Liability) 

Personal Effects

Value of Tender & Outboard 

Medical Coverage

Chartered?

Paid Crew ?

Any past claims?

Lay up Period (If applicable):

From To

In the Water Out of the Water

If Yes, Describe below:



Will your boat be in the Hurricane Box (12:40N to 23:30N whilst between 55W & 85W) at any time from July 1 to Nov 1?
Please define your navigation area for the next 12 months using our
Yes No most popular navigation area list popup buttons below,
If your boat is going to be in a hurricane area (12N LAT to 24N LAT) during storm season (from July 1 to Nov 1), briefly describe storm precautions, caretaker and marina where the boat will be kept:

 

Or describe your own Custom Navigation Area below.


OTHER INFORMATION
Explain All Yes Answers in Remarks
Yes
Remarks
Is vessels ever chartered to others with captain?
If yes, is yacht owner operated?
Is vessels ever chartered to others without captain?
Is vessels used commercially or for business purposes?
Do you employ a paid captain or crew? If so how many?
Is vessels used for water skiing or recreational diving?
Was any operator involved in a marine loss in the last 10 years?
Has any carrier cancelled, non-renewed or declined coverage?
Is the vessels used for racing?
For fare paying passenger vessels, advise the maximum/average # of passengers per trip ___/___ # trips annually ____

Who Referred you to Blue Water Insurance, Inc.