Boat/Yacht Insurance Select Your Agent*Simon VaculaChad BakerRebecca HayesBlaine ScottJared TollesonPrimary Insured's First & Last Name* First Last Mailing Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Primary Insured Cell Phone Number*Do we have permission to text you about policy changes?* Yes No Primary Insured Email* Primary Insured Gender* Male Female Primary Insured DOB* MM slash DD slash YYYY Primary Insured Driver's License Number*Driver's License State*Select OneAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificBoat InformationLength*in feetYear*Manufacturuer*Model*Hull Material*Select OneAluminumFiberglassSteelWoodOtherType*PowerSailEngine Type*Select OneInboardInboard/OutdriveOutboardNoneFuel Type*Select OneDieselElectricGasolineHybridNoneTotal Horsepower*Speed*Watercraft Storage Location* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Type of Storage*Private ResidenceMarinaYacht ClubBoat Storage FacilityPublic Lot (including apartment/condo)OtherYears of Experience Operating a Watercraft*Principal Operator Boating Education Level*AdvancedBasicNoneSafety CourseState CoursePower Squadron/Coast Guard AuxiliaryIs this vessel a Personal Watercraft (a Jet Ski or Wave Runner versus a boat)?* Yes No Is this vessel used for Private Pleasure Use Only?* Yes No Is this vessel chartered?* Yes No Is this a full-time live aboard exposure?* Yes No Is this a houseboat that has salt water/coastal exposure?* Yes No Have there been any boating losses in the last 3 years?* Yes No Is the principal operator over 25 years old?* Yes No Are there more than 2 unrelated owners/operators?* Yes No Does this boat/yacht go faster than 75 mph?* Yes No Are there more than 2 motor vehicle incidents per operator and/or 3 per household?* Yes No Has this client's insurance ever been canceled, declined, or non-renewed?* Yes No Does any operator have any criminal convictions(Arson/Burglary/DUI) within the past 5 years?* Yes No Is the boat used on coastal waters of the Atlantic Ocean, the Pacific Ocean, or the Gulf of Mexico?* Yes No The following questions apply to any watercraft to be insured on this policy - Check all that apply Rented or leased to others? Used for business purposes? Previously salvaged? Permanent living quarters? High performance? Homemade or kit? More than two motors? Exposed engine, other than outboard motors? Owned by business? Upload your current boat policyAccepted file types: doc, pdf, jpg, Max. file size: 512 MB.State law requires that the customer be informed that credit information will be used during the quote/application process and that the customer be provided with a copy of the current statement. This information may also be used to provide you with a quote for other insurance products we offer. By submitting this form I certify that I have reviewed the application information contained herein. I verify that the information is true, correct and complete.* I agreeState law requires that the customer be informed that credit information will be used during the quote/application process and that the customer be provided with a copy of the current statement. This information may also be used to provide you with a quote for other insurance products we offer. By submitting this form I certify that I have reviewed the application information contained herein. I verify that the information is true, correct and complete.CAPTCHA
