Wozencraft - RATE REQUEST

Please complete the form below for a Rate Request. *required

Owner/Operator Resume

Total years of boating experience:

years

Total years of ownership experience:

years

Driver's License Number:

Marital Status:

Boating Courses:

USPS USCG
OTHER:

Date of Birth:

/ /

Prior Boats OWNED:

List the waters or areas you intend to navigate: (Atlantic, Great Lakes, Pacific, Mexico, etc..):

Anticipated Trips:

Losses:

Yes No

If Yes, Year of Loss Total Paid: $
Brief description of loss:

Current Insurance Carrier:

Premium:

Live Aboard:

Yes No

Commercial Use:

Yes No

Youthful Operators:

Yes No

DUI: (last 5 years)

Yes No

Paid Crew:

Yes No
If Yes, #

# of Charters:

6 Pac 12 Pac

Driving Record for last 3 years as listed on MVR (Motor Vehicle Record).

# Tickets:

# Accidents:

Coverage Required
Hull: (amount to insure hull & motor)	$
Trailer:	$
Liability:	$
Additional Coverage Requested:	Yes No
If yes, please explain:

How did you hear about us:

IMPORTANT NOTES

This quote may not match the specific terms, conditions and exclusions requested in the original submission.
This quote is valid for 30 days from the date quoted, unless extended in writing.

Boat Description
Year:
Length:	ft in
Builder/Make:
Model:
Hull Material:
Weight:	lbs
Name of Boat:
Tender/Dingy:	Yes No
If yes, please explain:

General Information
Storage/Mooring Location:	Zip:
Purchase Price:	$
Date of Purchase:	/
Laid Up Dates: (months not in use)	to
Dry Indoors Dry Outdoors Afloat
Date of Last Survey:	/
Dry Afloat
Engine Information
Engine(s):	# Make: Year:
Total Horsepower:
Fuel:
Top Speed: (be honest!)	mph
Turbo:	Yes No
Blower/Supercharger:	Yes No
Fume Detector:	Yes No
Fixed Fire System:	Yes No
Engine Type:	OB IN I/O JET-DRIVE