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PERSONAL INFORMATION
Name
Address
City
State
Zip Code
E-Mail
Home Phone
Work Phone
Fax Number
Insured's Social Security Number
Date Of Birth
Present Insurance Carrier
Expiration Date
Premium
Years Of Boating Experience
Any Boating Courses Taken?	Choose One Yes No
Length And Make Of Boats Previously Owned
Motor Vehicle Driving Record For Last 5 Years
BOAT INFORMATION
Year
Length
Make
Model
Hull Material	Choose One Fiberglass Wood Steel Aluminum
ENGINE(S)
Number Of Engines
HP Of Each Engine
Engine Manufacturer
Type Of Engine	Choose One IB OB IO
Maximum Speed Of Boat
NAVIGATION
Inland Waters	State Of
Coastal Waters	State Of
Other (Explain)
LOSSES
Date, Type, Amount Paid
Date, Type, Amount Paid
Date, Type, Amount Paid
Date, Type, Amount Paid
COVERAGE REQUESTED
Hull And Equipment Value
Trailer
Deductible	1%      2%

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© Copyright 2001-2006 Rotatori Insurance Agency. All rights reserved.
Rotatori Insurance Agency • PO Box R - 1101 Putnam Pike, Chepachet, RI 02814
Tel: 1-800-351-7888 • Fax: 401-568-8007 • E-Mail: info@rotatoriinsurance.com