Name: *

Date of Birth: *

Assn. Member Number:

How did you hear about us? *

Address:

City, State, Zip:

Home Phone:

Work Phone:

Email: *

Does more than 49% of your income come from tournaments? * Yes   No

Are you a fishing guide? *

Yes   No

Watercraft Information

Year *   Manufacturer *  Model *

Length *  ft.  in.  Beam:

Hull Material:

Fiberglass Aluminum Wood

Type: *

Bassboat Runabout Pontoon Deckboat Walleye
Other* (details)

* If Other please explain:

Engine #1: *

Horsepower* Make* Model* Year*

Engine #2:

Horsepower  Make  Model  Year

Type: *

Outboard   Inboard   I/O   Water Jet   None

Trailer: *

Year *   Make *

Trolling Motor:

Lbs. of Thrust   Make   Model   Year

Equipment:

Depth/Fish Finder   Stainless Prop   GPS

Anti Theft Trailer   Anti Theft Boat   Anti Theft Prop

VHF Radio   Vapor Detector   Auto Halon/CO2

Purchase Date: *

Total Purchase Price: *

Operator's Experience

Total years of boat ownership: *    Total years of operating experience: *

Licenses Held:

Previously owned boats:

Make * Model * HP * Years Owned *

Make    Model    HP    Years Owned

Make    Model    HP    Years Owned

Boating Courses Completed & Year:

Any Watercraft Losses? * Yes   No

If yes:
Date   Circumstances   $ Amt. Paid

Date   Circumstances   $ Amt. Paid

Date   Circumstances   $ Amt. Paid

Any Auto or Watercraft Violations or Suspensions? * Yes   No

If yes:
Date   Circumstances

Date   Circumstances

Date   Circumstances

Intended Use

Waters Navigated: *

Inland   Great Lakes   Coastal   Chesapeake Bay ONLY
Other* (details)

If Other please explain:

State where vessel is kept. *    Zip: *

Coverage Desired

Hull & Equipment:

$

O/B Motor #1:

$

O/B Motor #2:

$

Trailer:

$

Trolling Motor:

$

Personal Effects:

$ ($2000 or $2500 included))

Watercraft Liability: *

$50,000   $100,000   $300,000   $500,000
$1,000,000 (Pro Angler/Fishing Guide ONLY)

Deductible: *

$100   $250   $500 (standard)   $1000

Optional Coverage

Advantage Plus What's this?
Contaminate/Fuel Spill Coverage What's this?
Fishing Tournament Fee Reimbursement What's this?
Pro Angler/Guide Endorsement What's this?
NAVIGUARD™ MBI What's this?
Custom Wrap Endorsement What's this?
Total Replacement Cost What's this?

Current Insurance

Issuing Company:

   Exp. Date:

Current/Renewal Premium:

$

Has vessel been continuously insured for the past 12 months?   Yes   No

If "No" please explain: