Name:                                            

Age:   

Date of Birth:  (mm/dd/yyyy)

NPAA #: 

Address: 

City/State/Zip: 

Phone Home/Work: 

Email: 

Watercraft Information

Year: 

Manufacturer: 

Model: 

Length: 

Hull Material Type 

              Fiberglass             Aluminum           Wood

              Bassboat               Runabout              Pontoon

              Deckboat              Other: 

Engine #1:  HP              Make                  Model                   Year

Engine #2:  HP              Make                   Model                        Year

     Trailer:   Year           Make

Type:   

                Outboard    Water Jet   Inboard / Outboard

               Inboard        None

Trolling Motor:

                 lbs. of Thrust           Make             Model             Year 

Equipment:

     Depth/Fish Finder    Stainless Props       GPS

     Anti Theft Trailer       Anti Theft Boat      Anti Theft Prop

     VHf Radio                Vapor Detector    Auto Halon/CO2

Operator's Experience

        Years:      Owning:          Operating: 

Licenses Held:  

Previous Owned

Watercraft (including

Make, Model,

and  HP): 

Boating Courses

Completed

(Year):    

List Watercraft

Losses (Explain):  

Auto Violations

(Last 3 Years):     

Waters Navigated  (Check all that apply)   Inland Waters   Great Lakes     Canada

Intended Use  (Check all that apply)     Guiding    Tournaments   Recreation

Purchase Information

          Date                     Total Purchase Price

Coverage Desired

Hull and Equipment:  $ 

       O/B Motor #1:  $ 

       O/B Motor #1:  $ 

                   Trailer:  $ 

       Trolling Motor:  $ 

Personal Effects:  $   

Watercraft Liability:    

   $300,000       $500,000       $1,000,000

Deductible

            $500 (Standard)    

           $1,000 (Pro Angler/Guide Endorsement only)

Optional Coverage

     Advantage Plus

     Containment/Fuel Spill coverage

     Fishing Tournament Fee Reimbursement

     Pro Angler/Guide Endorsement

     NAVIGUARD MBI

Current Insurance

Issuing Company:   

Exp Date: 

Current / Renewal Premium