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NAME:
ADDRESS:
CITY, STATE, ZIP:
PHONE:
E-MAIL:
REFERRED BY (PERSON OR SEARCH ENGINE):

VESSEL DESCRIPTION AND OPERATION

YEAR BUILT
LENGTH:
BUILDER :
HULL MATERIAL:	Fiberglass Aluminum Steel Wood Other
BOAT NAME:
TOTAL ENGINES:	1 2 3
ENGINE YEAR:
HORSEPOWER EACH:
MANUFACTURER:
FUEL::	Diesel Gas
AUTO FIRE CONTROL	None Halon CO2
TOP SPEED
	VHF RADAR AUTO PILOT GPS SSB DEPTH FINDER
MOORING LOCATION:
NAVIGATION AREA:

INSURANCE COVERAGE REQUESTED

PURCHASE PRICE:
PURCHASE DATE:
INSURED VALUE:
LIABILITY LIMIT
DINGHY VALUE
TRAILER VALUE:
# PAID CREW
DATE LAST SURVEY:
SURVEY TYPE:	none hauled in water
YOUR AGE:
YEARS EXPERIENCE:
PRIOR BOATS OWNED:
BOATING COURSES:	USCG USPS ASA OTHER USCG LICENSE USCG LICENSE TYPE: none six pack 50 ton 100 ton 500 ton 1600 ton 3000 ton Unlimited
EXPLAIN OTHER:
INTENDED USE:	Personal Charter Commercial Other
TYPE OF CHARTER:	None Six pack Twelve pack Other
CLAIMS PAST 5 YRS:	NO YES
EXPLAIN CLAIM: