Inter-Agency Insurance Service, Inc.

Name

Address

City

State Zip

Work Phone

Home
Phone

E-mail

Do you own a home? Yes No

How long at present address?

Year: Make: Model:

Length: Hull Construction:

# Engines: HP: Type:

Top Speed: mph Engine Year: Make:

Purchase Date: Price: Value Now:

Tender: Yes No If yes, Value:

Trailer: Yes No If yes, Value:

Onboard Equipment (check all that apply):
VHF Radar Loran Depth Sounder Halon
Other(s):

Vessel's Current Location:

Lay Up Location:
Months: Ashore Afloat

Use of craft (check all that apply):
Private Pleasure Live Aboard Charter

Paid Captain and/or Crew (if yes, give details): Yes No
Details:

Navigational Limits:

OPERATOR ONE

Name: DOB:
Driver's License #: Occupation:
Years Experience: Boating Courses:
Prior Owned Vessels:

OPERATOR TWO

Name: DOB:
Driver's License #: Occupation:
Years Experience: Boating Courses:
Prior Owned Vessels:

CURRENT INSURANCE INFORMATION

Present Company: Exp. Date:
Annual Premium:

Detail of losses in last five years (if none, state "None"):

Has current vessel been surveyed? Yes No
If yes, most recent survey date:

AMOUNT OF COVERAGE REQUIRED:

Vessel & Equip $		Deductible $
Tender $		Deductible $
Personal Effects $		Deductible $
Liability Limit $		-0- Deductible Applies
Medical Payments $		-0- Deductible Applies
Uninsured Boater $ STANDARD		-0- Deductible Applies