Watercraft Owners Name

First Name

Last Name

Mailing Address

City

State
Massachusetts New York Connecticut Vermont New Hampshire Rhode Island

Zip

Home Phone

Work Phone

Fax Number

Email Address

Number of years boating

Number of years as a watercraft owner

Please complete this section only if the watercraft is owned by more than one party.

Watercraft Co-Owners Name

First Name

Last Name

Mailing Address

City

State
Massachusetts New York Connecticut Vermont New Hampshire Rhode Island

Zip

Home Phone

Work Phone

Fax Number

Email Address

Number of years boating

Number of years as a watercraft owner

Watercraft Information
Please complete this section.

Manufacturer

Model

Year

Length

Type of Boat

Power
Sail
Other

Engine type
Inboard
Outboard
Inboard Outdrive
Jet
Twin Engine
N/A

Fuel Type
Gas
Diesel
N/A

Total Engine Horsepower

Maximum Speed

Value of Watercraft and Motor(s)

Trailer Information
Please complete this section.

Manufacturer

Year

Value of Trailer

Usage Information
Please complete this section.

Primary waters to be navigated
Inland Coastal
Moored Docked Trailered

City

State
Massachusetts New York Connecticut Vermont New Hampshire Rhode Island

Winter lay up location
Residence Marina
Hauled Afloat

Lay up period from
to (mm/dd)

If afloat, Bubblers System? Yes No

City

State
Massachusetts New York Connecticut Vermont New Hampshire Rhode Island

Other Notes

Safety Information
Please complete this section.

Fume detector
Yes No

Depth Finder
Yes No

GPS
Yes No

Loran
Yes No

VHF Radio
Yes No

US Coast Guard/Power Squadron Course
Yes No

Radar
Yes No

Licensed Captain
Yes No

Auto CO2 Halon Fire Extinguisher
Yes No

Watercraft Liability Limit
$300,000 $500,000

Operators Information
Please complete this section for any people who will be regularly operating the watercraft.

Operator One

Name

Date of Birth (mm/dd/yy)

% of Use (all operators should add up to 100%)

Driver's license number

Drivers License State
Massachusetts New York Connecticut Vermont New Hampshire Rhode Island

Operator Two

Name

Date of Birth (mm/dd/yy)

% of Use (all operators should add up to 100%)

Driver's license number

Drivers License State
Massachusetts New York Connecticut Vermont New Hampshire Rhode Island

Operator Three

Name

Date of Birth (mm/dd/yy)

% of Use (all operators should add up to 100%)

Driver's license number

Drivers License State
Massachusetts New York Connecticut Vermont New Hampshire Rhode Island

Operator Four

Name

Date of Birth (mm/dd/yy)

% of Use (all operators should add up to 100%)

Driver's license number

Drivers License State
Massachusetts New York Connecticut Vermont New Hampshire Rhode Island

Past Boating Claims Section

Have you had any previous boating claims?
Yes No
If you have had any previous boating claims, please complete the remainder of this section.

Please briefly describe the reason for the claim.

Please provide the amount paid by your insurance company for this claim.