P.O. Box 45520
25730 First Street
Westlake, OH 44145
Phone: 440-892-3636
Fax: 440-892-3630
Toll Free: 800-837-3640

Boat Insurance Form

Please complete the form below (* required)

Personal Information

Name *	Address *

City *	State *

Zip*	Home Phone

Work Phone	Email

Best Time to Call	Date of Birth

Social Security #	Driver's License #

Other Operators

Any Motor Vehicle Accidents/Violations in the Past 3 Years? Yes No
If Yes, Please Explain

Years of Experience
As Owner	As Crew

Types of Boats Owned and Operated

Any Formal Course? Describe:

Have You Had Any Watercraft Losses or Claims in the Past 5 Years? Yes No
If Yes, Please Describe

Boat Information

Year of Boat	Length of Boat

Manufacturer	Model

Construction	Total Horsepower

Type:	Engine Type:
Sail Cruiser Cuddy Runabout Pontoon Houseboat	Outboard Inboard Inboard/Outboard Jet
Engines:	Fuel:
Single Twin	Gas Diesel
Top Speed	Fuel Detector

Auto Fire Extinguisher	Navigational Equipment

Water Skiing

Navigation and Use

Use:	Navigational Limits:
Private/Pleasure Charter/Fishing Charter/Sightseeing	Great Lakes Inland Lakes Other
Date Normally Launched	Date Normally Hauled

Where Moored in Summer	Where Stored in Winter

Insurance Information

Amount of Insurance on this Boat	Deductible

Trailer Value

Water Craft Liability Limit:	Medical Payments:
$100,000 $300,000 $500,000 $1.000,000	$1000 $2000 $3000 $4000 $5000

Fitzgibbons Arnold & Co. Teaching our clients to be better insurance consumers.