Be specific to tell if
accidents are "at-fault" or "NOT-at-fault" -
(carriers require proof on NOT-at-fault
accidents); Also, be specific as to TYPE of
violations, and approximate DATES of each in the
fields below:
Number & Type of Accidents last 3
years:
Number & Type of MINOR violations last
3 years:
Number & Type of MAJOR violations last
3 years:
Minnesota Drivers License #:
OPERATOR
INFORMATION #2 (if none, leave
blank)
Name:
Birthdate:
Sex:
Social Security #:
Be specific to tell if
accidents are "at-fault" or "NOT-at-fault" -
(carriers require proof on NOT-at-fault
accidents); Also, be specific as to TYPE of
violations in fields below:
Number & Type of Accidents last 3
years:
Number & Type of MINOR violations last
3 years:
Number & Type of MAJOR violations last
3 years:
Minnesota Drivers License #:
VESSEL &
UNDERWRITING INFORMATION
Year
of Boat:
Make
& Model (be specific):
Boat
Length:
Hull
Type (wood, Metal, fiberglass,
etc):
Max.
Speed (in MPH):
Market Value: $
Engine Make:
Engine Type: (Inboard,
I/O, Jet)
Engine Horse Power:
Fuel
Type: (Gas, Diesel, etc.)
Trailer Cov. Needed?
Yes No
Yr./Make/Model of
Trailer:
Trailer Value: $
Where is boat moored or
stored?
Describe waters boat taken
on?
Describe boat general
usage? (fishing, ski, etc.)
VESSEL
COVERAGES:
Limits of Liability:
$15/30 BI / 10 PD $25/50
BI / 15 PD $50/100 BI / 25
PD $100/300 BI / 50 PD $250/500 BI / 100 PD
Hull Coverage:
NO Coverage $250
Deductible $500 Deductible $1000 Deductible
Water Ski Medical Coverage?
Yes No
Uninsured Motorists
Cov.?
Yes
No
Comments or Remarks: (List
additional drivers, special coverages, etc.
here)
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