Watercraft Application

Model Year:

Make:

Model:

Zip code for the primary location of your watercraft:

Specific zip code location:

Is the watercraft co-owned by someone living in a separate household?
(other than financial institution or leasing company)
 Yes No

Watercraft use:(select "Pleasure" if no other choice applies)
Pleasure use exclusivelyRacing/Speed contests Business/Commercial useRented or leased to othersPrimary residence

Would you like to insure your trailer?(Comprehensive and Collision coverage must be selected)
 Yes No

Market value of watercraft:(enter whole dollar numeric values only, ex: 15000)
(include the value of the trailer if insured)

Is the current owner of this watercraft the original owner?
 Yes No

Propulsion Type:
Inboard/OutboardInboardOutboardJet

Hull Material:(Roplene, carbon fiber, and rotomolded technologies should be classified as Fiberglass/Composite)
Fiberglass/CompositeAluminumInflatable WoodSteelOther

Engine/outdrive modified to enhance performance?
 Yes No

Maximum speed of watercraft in miles per hour: (enter numeric characters only)

Does your watercraft have an exposed engine?
 Yes No

Would you like to add an additional watercraft?
 Yes No

Information for Driver
First Name:
Middle initial:
Last Name:
Birth date:
Name suffix: NoneSr.Jr.IIIIII
Gender:  Male Female

Marital status:
SingleSeparatedMarriedWidowed

Driver's license status:
ValidPermitSuspendedNot licensedForeign's driver licence

Taken an approved watercraft safety course?
 Yes No

Has this driver had any:
• At Fault Accidents, Claims, Violations, or Not At Fault Accidents in the last 3 years, or
• Any Driving Under the Influence violations that occurred on or after 1/1/01?
 Yes No

Would you like to add an additional driver?
(Which drivers and family members must I include?)
 Yes No

Do any drivers belong to a watercraft association?
(membership number will be required for this discount)
No association membershipUSCG AuxiliaryUS Power Squadron

Policy Coverages

Bodily Injury & Property Damage:
$15,000 person/$30,000 accident/$10,000 property damage$25,000 person/$50,000 accident/$10,000 property damage$25,000 person/$50,000 accident/$25,000 property damage$30,000 person/$60,000 accident/$15,000 property damage$50,000 person/$100,000 accident/$25,000 property damage$50,000 person/$100,000 accident/$50,000 property damage$100,000 person/$300,000 accident/$50,000 property damage$100,000 person/$300,000 accident/$100,000 property damage$250,000 person/$500,000 accident/$100,000 property damage$100,000 Combined Single Limit (CSL)$300,000 Combined Single Limit (CSL)$500,000 Combined Single Limit (CSL)

Uninsured/ Underinsured Boaters:
No coverage$15,000 person/$30,000 accident$25,000 person/$50,000 accident$30,000 person/$60,000 accident$50,000 person/$100,000 accident$100,000 person/$300,000 accident

Medical Payments:
No coverage$1,000 each person$2,500 each person$5,000 each person$7,500 each person$10,000 each personnt

Fishing Equipment:
No coverage$1,000 ($250 deductible)$2,500 ($250 deductible)$5,000 ($250 deductible)$10,000 ($250 deductible)

Vehicle #1 - 2005 Chaparral 310 Signature Cruiser

Physical Damage Options:
No CoverageAgreed ValueActual Cash Value

Comprehensive:
$100 deductible (Agreed Value)$250 deductible (Agreed Value)$500 deductible (Agreed Value)$1,000 deductible (Agreed Value)$2,500 deductible (Agreed Value)$5,000 deductible (Agreed Value)

Collision:
$100 deductible (Agreed Value)$250 deductible (Agreed Value)$500 deductible (Agreed Value)$1,000 deductible (Agreed Value)$2,500 deductible (Agreed Value)$5,000 deductible (Agreed Value)

On-Water Towing:
No coverage$300$500$1,000$2,500

Coastal Navigation:
75 Nautical Miles125 Nautical Miles

Replacement Cost Personal Effects:
$0$1,000$2,000$3,000$4,000$5,000

Roadside Assistance: Included

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