Effective Date:
Your Name:
Your Mailing Address: Street

City & State                                                     Zip
  
E-mail Address:
Daytime Phone #:
Choose One: Please call me with quote premium.
Please send quote via e-mail.
Description of Property:
Motor type:
 Number of Engines:
 Boat Type:
 Other Boat Type
Fuel:
 Maximum Speed:
 Hull Material:
 Other Hull Material:
Insured Watercraft:
Boat:
Year        Manufacturer                              Model

Serial Number                                                     Length           TotalHP
Outboard Motor:
Year        Manufacturer                              Model

Serial Number                                                     TotalHP
Trailer:
Year        Manufacturer                              Serial Number
Coverages:                                           Limits:
Boat (Including Auxiliary Equipment, please break down o/b information)
Outboard Motor 1.
(ACV Coverage)
Outboard Motor 2.
(ACV Coverage)
Boat Trailer
Personal Property
($500 Automatic)
Commercial Towing
($400 Automatic)
Boat Liability
(ACV Coverage)
Medical Payments
($1000 Automatic with Liability)
Uninsured Boater
Optional Coverages
 		Agreed Value Endorsement
Actual Cash Value
Fishing Equipment - Limit:  
Safety Equipment:
Check all that apply:
GPS
Automatic CO2 (Halon)
Ship to Shore Radio (VHF)
Depth Sounder
Electronic Burglar Alarm 		Radar
Plotter
EPIRB
Vapor Detector Alarm
Operator Information:
Date of Birth:
 Years of Boating Experience:
Waters to be Navigated:
Inland waters of the following states:
 Coastal waters of the following states:
Is the boat chartered or used for other than private pleasure purposes?    Yes    No
Previous Loss Information
Please describe any losses or claims filed on your Boat Insurance in the last 3 years:

Date of loss:               Type of loss:                                                Amount of claim:
Additional Comments
Please use the box below to enter any additional information you wish to include:
        
myagent@veenstrainsurance.com
Local: (248)553-3000 . Toll free: (800)445-6554 . Fax: (248) 553-8482
31700 W. 12 Mile Road . Suite 200 . Farmington Hills . Michigan . 48334-4461