| Contact Information |
| Name |
|
| Email Address |
* REQUIRED TO SUBMIT FORM |
| Telephone Number |
|
| Preferred Method of Contact |
|
| Street Address |
|
| City or Town |
|
| State |
|
| ZIP Code |
|
| Operators |
|
List names along with their date of birth
and if each operator has completed Coast
Guard Auxiliary or Power Squadron course: |
|
| Boat Information |
| Is the boat currently insured? |
|
| If yes, when does the policy expire? |
|
| Type of boat: |
|
| What
is it used for? |
|
| Where is vessel stored? |
|
| Waters navigated? |
|
| Hull Information |
| Year Built: |
|
| Make and Model: |
|
| Hull Type: |
|
| Length: |
feet |
| Estimated Market Value: |
|
| Maximum Speed: |
miles
per hour (MPH) |
| Personal Effects? |
(value) |
| Engines |
| #1 Engine Year & Make: |
|
| Type: |
|
| Fuel Type: |
|
| Estimated Value: |
$
(Outboard only) |
| Horsepower: |
|
| #2 Engine Year & Make: |
|
| Type: |
|
| Fuel Type: |
|
| Estimated Value: |
$
(Outboard only) |
| Horsepower: |
|
| Trailer |
| Trailer? |
|
| Make: |
|
| Value: |
$
|
| Liability Coverage |
| Liability Coverage: |
|
| Medical Payments: |
|
| Waterski Medical Needed |
|
| Has any listed operator been
involved
in a boating accident within the past 5 years? |
|
| If yes, please provide details: |
|
Has your boat and/ or equipment
suffered
damage from any cause within the
past 5 years? |
|
| If yes, please provide details: |
|
Has any listed operator been
involved in an
auto accident or received a moving traffic citation within the past 3 years? |
|
| If yes, please provide details: |
|
| Additional Comments |
|
| |
|
| |
|
