REQUEST TO ADD INSURANCE WATERCRAFT 	
BOAT Information	
Boat Name         				
Serial #       	
Year      	Length       feet	Make/Model           	Horsepower      	
Planned Boat Usage
How will the boat be used? 

Where will it navigate – check all that apply:
 Inland lakes, rivers and streams  Tidal rivers    Ocean    Other:        	
Are you adding a boat trailer to the insurance policy?  Yes   No  
 Liability only          Liability and Physical Damage 

	
Occupancy
What is the maximum number of crew that might be aboard?      
What is the usual number of crew that might be aboard?      
What is the maximum number of non-crew that might be aboard?     
What is the usual number of non-crew that might be aboard?     
Other Occupancy Notes or Special Equipment (if applicable):      	
Boat Status
Is the boat in your possession at this time?  Yes   No If no, explain.

Will the boat be out of the water during the winter season?   Yes   No 
Was a survey completed?  Yes   No	If yes, provide us with a copy via email.	

Which Agency does this boat belong to?

	
INSURANCE COVERAGE ORDER	
Desired effective date:  As soon as possible; or on this specific date:      	
Protection and Indemnity Per Occurrence Limit Desired:                  	             	
Hull Coverage Per Occurrence Limit Desired   $       agreed / market value. 
FYI- This is not a Replacement Cost Policy it is based on agreed/market value.	
ADDITIONAL REQUESTS OR INFORMATION	
     	
Your Name:        			Your phone number:      	

Email this form to amber.dangler@maine.gov