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Name* Address City* State* Select Pennsylvania Zip: Please supply either a Daytime or Evening Phone Number and the best time to call. Day Time Number: Evening Number: (570) Best Time To Call* Select Morning Afternoon Evening E-mail:* Request Watercraft Insurance Marital Status: Single Married Divorced Separated Widowed Current insurance carrier* (If you do not have a current insurance carrier type in NONE) How Long*   years Policy Expiration Date Social Security# Drivers License # Number of years experience Member of any boating association Yes No Purchase price: Loss Payee Yes No Loss Payee  (if applicable) Name: Address: City: State: Zip: Balance Due: Has insurance ever been declined: Yes No If Yes, explain List and detail any losses or claims Watercraft Information Year: Length: Model: Builder: Hull Identification #: Name of Boat: Hull Type Cruiser Trawler Sail Houseboat Runabout Personal Watercraft Hull Material Fiber Glass Wood Other If other, Engine Gas Diesel Inboard Outdrive/I/O Outboard Jet Drive Year: Manufacturer: How many: HP each: Max Speed (MPH): Engine(s) S#: Trailer Year: Length: Manufacturer: S#: Tender Year: Length: Manufacturer: S#: Tender's Motor Year: Length: Manufacturer: S#: Equipment Loran Yes No Radar Yes No Halon Yes No GPS Yes No Depth Finder Yes No VHF Yes No Other: Navigation Chesapeake Bay Trib. Yes No Inland Water Yes No Specify Waters Atlantic Coast between and Vessel will be laid up Ashore Afloat Where: Vessel in excess of 24' ONLY Ever transported overland Yes No If yes, how many miles? Chartered Yes No   Ever used for water skiing? Yes No Coverage Effective Period From to   VALUES DEDUCTABLE PREMIUM Hull and Machinery Outboard Motor Equipment Tender and its Motor Trailer Liability Medical Payments Overland Transp. (miles) Uninsured Boaters Personal Effects Assistance/Towing Total Premium Additional Information: NOTE: All asterisked* fields must be completed for a successful submission. Thanks!