Lighthouse Marine Insurance

Pleasure Craft

Name:

Age: Occupation:

Address:

City:

State: Zip:

Work phone:

Home phone:

Present Insurer:

Fax:

Email Address:

Current premium:

Exp. date of current policy:

Name of Boat:

Hull Material:

Manufacturer:

Model: Year: Length:

Engine:

Single Twin Gas Diesel Engine manufacturer:

Total horsepower:

Top speed:

Automatic fire extinguishing system: Yes No Bilge alarm: Yes No Fume alarm Yes No

List of electronics:

Last survey date:

Name of surveyor:

Market value:

Replacement value:

Boating courses completed:

Previous vessels owned:

Vessel location:

Years boating experience:

Areas of navigation:

Purchase price:

Date of purchase:

Amount of hull insurance desired: Liability coverage: Other:

Hull deductible:

Tender value:

Outboard value:

Boating losses in last 5 years? Yes No If yes explain:

Personal effects amount:

Additional comments: