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Private Client Division

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First Name *

Last Name *

Primary Physical Residence

City

State

Zip Code

Mailing address (if different)

Date of Birth

Drivers License Number

Home Phone

Cell

Fax

Email *

Marital Status

Home Ownership Status

Gender

Year Built

Length of Vessel

Manufacturer

Model

Hull ID

Requested Effective Date

Purchase date or financial loan closing date

Purchase Price (in USD)

Include taxes; title and registration fees

Number of engine(s)

Maximum Speed (mph)

Horsepower each engine

Engine Type

Hull Material

Fuel Type

Has the applicant previously owned other watercraft?

Yes

No

If yes then fill in the following details.

If multiple watercraft, list largest to smallest.

Make(s)

Length(s)

Number of Years Owned

Has the applicant previously operated other watercraft?

Including family, friends and rental boats.

If yes then fill in the following details.

Make

Length

Number of Years Operating

Any boating claims/losses within last five years?

Yes

No

If you had a loss please provide the following details.

Date of Loss

Cause of Loss

Nature of Loss

Amount of Loss (USD)

Has the applicant or any operator had any vehicle driving violations in the past 5 years?

Yes

No

(ticket, accident, felony, DUI)

If yes then tell us about the violation.

Operator Name

Violation Description

Date of Violation

Additional Experience, Claims or Violations?

If the applicant has owned more than one boat or has had additional claims or driving violations in the past 5 years provide details.

Mooring Address

If marina or storage facility, please include the name of the business.

City

State/Territory

Zip/Postal Code

Requested Navigation Territory

Vessel Use

Private Pleasure

Charter (6 pack)

Charter (Bare Boat)

Live-aboard

Types of Storage:

Loss Payee

Loss Payee Address

Trailer Year

Trailer Make

Trailer Serial

Trailer Value

Engine #1 Year

Engine #1 Make

If Outboard, Engine #1 Serial

Engine #2 Make

Engine #2 Year

If Outboard, Engine #2 Serial

Hull Value (less trailer value)

P&I Liability

Trailer

Medical Payments

Uninsured Boater

Personal Effects

Towing Coverage

Any Relevant Files

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Traverse City, Michigan
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Recreational Division

Private Client Division

Global Marine Insurance Agency, a division of Specialty Program Group LLC
12935 S. West Bayshore Drive, Suite 205, Traverse City, MI 49684 | 800.748.0224 Fax 231.947.4407

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