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-- Insure Your --
Auto
Boats & PWC
Homeowner's
Motorcycles
RV's
Sports & ATV's
Fort Lauderdale Main Office
Cocoa Florida Office
Newport, RI Office
Boat Insurance Application
* Required
*
Requested Effective Date:
ex. XX/XX/XXXX
*
Full Name:
*
Email:
*
Home Phone:
Work Phone:
*
Street Address:
Address 2:
*
City:
*
State:
Select One
Florida
Georgia
*
Zip Code:
Date of birth:
ex. XX/XX/XXXX
*
Social Security Number:
**Note: Not required, but will assist in giving you the best rate.
Marital Status:
Yes
No
Home Owner:
Yes
No
*
*Drivers License #:
*
Drivers License Issuing State:
Other Operators:
Name, DOB,DL#, Relation to insured
Boat Information
Years of boating experience:
Vessels Length and Makes:
Active Boating safety course or License w/Certificate:
Yes
No
Any claims?:
Yes
No
Navigational Area:
Please Select
Florida
Atlantic
Gulf
Bahamas
Inland
Non-Tidal Waters
If yes what happened?:
Date / accident / claim $
*Year, Make, Model and Length of boat:
Primary Storage Location:
Include Address Zip and storage type
Is it used as a fulltime residence - Used as Live Aboard?:
Yes
No
Date purchased?:
Value of your boat:
Engine year: :
HP:
# of motors:
Engine Make:
Type:
I/O
I/B
O/B
Jet
Fuel Type:
Trailer Year:
Value:
Trailer Make:
Liability Limits and Coverage Requested:
Type of use?:
Personal
Commercial
Charter
Comments:
We work hard to earn your business!
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