Watercraft Insurance Questionnaire

Applicant's Information

1st Drivers Name

SSN

Address

City

State

Zip

Home Phone

Work Phone

Occupation

Sex

Male
Female

Birthdate

Years Experience

Safety Course

Yes
No

2nd Drivers Name

SSN

Occupation

Sex

Male
Female

Birthdate

Years Experience

Safety Course

Yes
No

Watercraft Information

Year

Make

Model

Hull ID #

Length

Beam

Construction

Purchase Date

Cost New ($)

Propulsion

Sailboat
Outboard
Inboard/Outboard
Twin Engine

Blue Book Horsepower

Actual Horsepower

Boat Speed

Motor Serial #

Motor Cost When New ($)

Date Motor Purchased

Any Modified Equipment

Cost ($)

Will the craft be used for waterskiing?

Yes
No

Trailer Information

Year

Make

Model

Serial #

Cost New ($)

Previous Loss Information

Previous Losses (include auto losses)

Yes
No

If yes, provide the following:

Date of Loss

Amount Paid ($)

At Fault?

Yes
No

Explanation

Date of Loss

Amount Paid ($)

At Fault?

Yes
No

Explanation

Any violations in the past 5 years? (including auto)

Yes
No

If yes, provide the following:

Date

Name