Owners Name Address

City State ZIP Website address

Email address Business Phone Number Cell Phone Number

How would you prefer to be contacted? E-Mail Business Phone Cell Phone

How long in business? Operate as DBA Corp. Individual

Effective Date Current Insurer Type of Boats Sold

Do you have a repair facility? Yes No

Number of Employees Do you offer benefits? Yes No

Building information - Do you Own or Lease

Square Footage Annual Repair Receipts Annual Gross Sales

Liability Limits Desired - 300K 500K One Million

Do you demmo vessles? Yes No

Where? How many boat shows do you plan to do?

This does not constitute insurance coverage being bound. This is only an information gathering form. Once the form is completed we will contact you for more information and to discuss your coverage request.