MyPolicy.com - Commercial Insurance - Special Programs - Commercial Outfitter / Guide Insurance Coverage

Section One - Personal Information

Name:

Address:

City:

State:

Zip:

Country:

Telephone:

Fax:

E-Mail:

Section Two - Boat Information

Year:

Make:

Model:

Length: feet

Engine Year:

Engine Make:

Engine Horsepower:

Engine Serial Number:

Hull I.D. Number:

Trailer Year:

Trailer Make:

Owner's Occupation:

Lienholder:

Lienholder Address:

Season lay-up period:From To

When not in use, this boat is stored *(describe location, i.e. on trailer, in yard, in locked garage, afloat in Boston Harbor):

Please describe any prior boats you have owned:

Section Three - Desired Coverage Limits

Boat: $Motor: $Trailer: $

Desired Deductible:

Liability Limit:

Medical Payments: $1,000

Uninsured Boaters Liability: $50,000

Is the boat currently insured? Yes No

If yes, what company currently insures your boat?

What company currently insures your home or apartment?

What is the expiration date of your current boat policy?

Has there been any lapse in insurance coverage for more than 30 days? Yes No

Section Four - Usage and Historical Information

Operators

Operator One

Name:

Date of Birth: 19

License Number:

Relationship to Owner:

Years of Experience:

Operator Two

Name:

Date of Birth: 19

License Number:

Relationship to Owner:

Years of Experience:

In the last 36 months has any operator:

a) been charged with operating a boat or motor vehicle under the influence of drugs or alcohol.Yes No

b) been charged with reckless or careless driving. Yes No

c) had more than 2 moving violations. Yes No

Historical Boat Information

This boat was purchased new used in (year)

Were there any losses in the last five years? Yes No

Please describe all prior accidents or losses including amounts paid:

Please describe any traffic violations within the last three years:

Please describe where, how often, and the purpose for which this boat is used:

Are passengers briefed, prior to launching, about the boat and its safety equipment? Yes No

Does watercraft have any deficiencies or un-repaired damage? Yes No

Is watercraft owned in whole or in part by anyone other than you? Yes No

Is watercraft stored in a public parking area such as an apartment house parking lot? Yes No

Will watercraft be used in tournaments? Yes No

Are you a full time guide? Yes No

If not, what is your occupation?

How many years of guide or charter experience do you have?

Please describe past experience:

Which bodies of water will you navigate with this vessel?

What boating licenses do you have?

What boating safety courses have you completed?

How many passengers are normally carried at one time?

Do you have a clean motor vehicle record (driving record)? Yes No

Have you or any other regular operator been convicted or pleaded no contest to a felony? Yes No

Section Five - Additional Information

Please indicate how you found our web site:

Prior Fitts Insurance Customer
Referral/Word of mouth

Please tell us who referred you:

Newspaper advertisement
Internet banner advertisement
Radio advertisement
Yellow Pages
Internet Search Engine

Google
Yahoo
Altavista
Webcrawler
Lycos
Other :

Other

Any Additional Comments:

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