Name:
Address:
Street
City State Zip
E-mail Address:
Daytime Phone:
Home Phone:
Choose One:
Call me with quote premium.
Send quote via e-mail.
Description:
Motor type:
Select
Outboard
Inboard
Outdrive
Water jet
Number of Engines:
Select
Twin
Single
None
Boat Type:
Select
Sail
Power
Other
Other Boat Type
Fuel:
Select
Gas
Diesel
None
Maximum Speed:
Hull Material:
Select
Fiberglass
Steel
Wood
Aluminum
Other
Other Hull Material:
Insured Watercraft:
Boat:
Year Manufacturer Model
Serial Number Length TotalHP
Outboard Motor:
Year Manufacturer Model
Serial Number TotalHP
Trailer:
Year Manufacturer Serial Number
Coverage: Limits:
Boat (Including Auxiliary Equipment, please break down o/b information)
Outboard Motor 1.
(ACV Coverage)
Outboard Motor 2.
(ACV Coverage)
Boat Trailer
Personal Property
($500 Automatic)
Commercial Towing
($400 Automatic)
Boat Liability
(ACV Coverage)
Select
$300,000
$500,000
$1,000,000
Medical Payments
($1000 Automatic with Liability)
Select
Automatic only
$Limit 1
$Limit 2
$Limit 3
Uninsured Boater
Optional Coverage
Agreed Value Endorsement
Actual Cash Value
Fishing Equipment - Limit:
Safety Equipment:
Check all that apply:
GPS
Automatic CO2 (Halon)
Ship to Shore Radio (VHF)
Depth Sounder
Electronic Burglar Alarm
Radar
Plotter
EPIRB
Vapor Detector Alarm
Operator Information:
Date of Birth:
Years of Boating Experience:
Waters to be Navigated:
Inland waters of the following states:
Coastal waters of the following states:
Is the boat chartered or used for other than private pleasure purposes? Yes
No
Previous Loss Information
Please describe any losses or claims filed on your Boat Insurance in the last 3 years:
Date of loss: Type of loss: Amount of claim:
Additional Comments
U
se the box below to enter any additional information:
© 2008 Hoover & Son Insurance Agency. All rights reserved.
