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| First Name: |
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| Last Name: |
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| Garaging Address: |
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| Garaging City: |
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| Garaging State: |
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| Garaging Zip Code: |
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| Phone Number: |
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| Fax Number: |
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| E-Mail Address: |
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Mailing Address
If Different from Garaging: |
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| Mailing City: |
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| Mailing State: |
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| Mailing Zip Code: |
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Driver One |
Driver Two |
Driver Three |
Driver Four |
| First Name |
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| Birthdate |
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| Sex |
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| Marital Status |
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| State Licensed |
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Yrs Boating
Experience |
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| Occupation |
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Boat |
Trailer |
Motor |
| Year |
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| Make |
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| Model |
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| Type |
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Identification
Serial Number |
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| Cost New Value |
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Hours Used
Each Year |
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Horsepower or
Motor Size |
h.p. |
| Boat Length |
ft. |
Ownership |
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Last 3 Yrs (Minors)
Last 5 Yrs (Majors) |
Driver 1 |
Driver 2 |
Driver 3 |
Driver 4 |
Minor Violations - Speeding,
Turn, Stop Sign, Red Light, etc. |
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| Accidents - Non Chargeable |
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| Accidents - Chargeable |
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Major Violations - Drunk Driving,
Reckless, Hit & Run, etc. |
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Bodily Injury |
Property Damage |
| Personal Liability |
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| Uninsured Motorist |
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| Medical Payment: |
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Boat & Motor |
Trailer |
| Comprehensive (Theft) |
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| Collision |
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| Current Insurance Company: |
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| Expiration Date: |
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| Current Premium $: |
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Questions or Comments
to help the Agent: |
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Questions or Comments
or additional coverages you may need: |
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