by W.R. Hodgens Marine Insurance, Inc.

Full Name:
Address:
City:
State/Province:
Zip code/Postal zone:
Country:
Drivers License State and Number:     --- Select --- AL AK AP AR AZ CA CO CT DC DE FL GU GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VI VT WA WI WV WY
Telephone:
Fax:
E-mail:
Occupation:
Date Of Birth:
Years of boating experience:
Size and builder of previous boats owned:
Are course/member certificates available?	Power Squadron USCG Auxillary USCG Captain License Other License
Motor vehicle driving record past 5 years:
Are there other operators of this vessel?	Yes No

VESSEL INFORMATION
NAME OF VESSEL:
YEAR:
MANUFACTURER/BUILDER:
MODEL:
TYPE OF VESSEL:	--- Select --- Sail Yacht Motor Yacht Other
LENGTH:
PURCHASE PRICE OF VESSEL:
DATE OF PURCHASE:
FLAG:	US Foreign
MAXIMUM SPEED:
HULL TYPE:	--- Select --- Catamaran Other
HULL MATERIAL:	--- Select --- Fiberglass Aluminum Steel Wood Other
ENGINES:	NUMBER: --- Select --- 1 2 3 FUEL TYPE: --- Select --- Gas Diesel HORSEPOWER EACH......... MANUFACTURER.............. --- Select --- Caterpillar Crusader Cummins Detroit Evinrude GM Honda John Deere Lehman Mercruiser MTU Perkins Volvo Yamaha Yanmar Other DRIVE TYPE........................ --- Select --- Inboard Outboard In/outboard Other
EQUIPMENT:	AUTO FIRE EXTINGUISHERS

VESSEL USAGE AND LOCATION
PRIVATE PLEASURE PART TIME CHARTER FULL TIME CHARTER IF CHARTER- MAX. NUMBER PAYING PASSENGERS/GUESTS: WHERE IS THE VESSEL MOORED?
NAVIGATION LIMITS
Waters navigated next twelve months:
Is vessel ever laid-up?	Yes No
What months is she out of commission?	--- Select --- Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec to --- Select --- Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
If laid up, is vessel stored:	--- Select --- Ashore In Water
Will anyone be living aboard the vessel during the policy period?	Yes No

PRESENT AND PAST INSURANCE INFORMATION
PRESENT INSURANCE CO.:
EXPIRATION DATE OF POLICY:
CURRENT PREMIUM:
Have you had any yacht insurance claims in the past 10 years?	Yes No

Please enter the year, amount, and a brief outline of the loss/claim.

COVERAGES REQUESTED
Hull and equipment value:$ Tender/Dinghy $ Year Trailer............ $ Year Survey Available: --- Select --- No Yes Survey Date Survey conducted: --- Select --- Afloat Ashore
LIABILITY COVERAGE  (Protection and indemnity) --- Select --- $100,000 $300,000 $500,000 $1,000,000 Other
Paid Crew --- Select --- Yes No Number of Paid Crew:
Comments

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Catamaran Insurance- Yacht, Boat and Marine, Sail and Power