Name Address

City State ZIP Email address

Phone Number Cell Phone Number

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

Location Address Effective Date

Business Form Corporation Partnership Individual LLC Other Limit of Liability Requested $300,000 Occurrence / $600,000 Aggregate $500,000 Occurrence/$1,000,000 Aggregate $1,000,000 Occurrence/$2,000,000 Aggregate

Prior Carrier Information

Last Year Two Years Ago Three Years Ago

Operations Information

1. Do you require your guests to sign a liabiity waiver? Yes No

2. Do you have a brochure or web page? Yes No

3. How many years have you been in business?

4. If you are a new venture, how many years of prior experience?

5. Are any operations conducted outside of the United States? Yes No

List safety procedures and/or attach safety guidelines

Captain Information

General Information

What type of operations do you have? Boat Rentals Whitewater Water Tours Fishing Charters Other

On what bodies of water does use take place? Rivers Lakes Ocean Bays/Inlets

Are life vests (PFD's) required? Yes No

Are life vests (PFD's) provided? Yes No

Are all of your charters captained? Yes No

Are all captains USCG licensed/certified? Yes No

What is the farthest distance from shore (in miles) your trips will be?

What type(s) of fish do you fish for?

What is the duration of each trip? Hourly half day Full Day Overnight

Additional Comments