REQUEST TO ADD INSURANCE WATERCRAFT

BOAT Information	
Boat Name:         			 Check here if not applicable: 	
Serial #       	
Year:      	Length:       feet	Make/Model:           	Horse Power:      	
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:        

Is this replacing another boat?  Yes   No  
Do we need to remove a boat from your policy?    Yes   No
Do we need to add a trailer to our insurance policy?  Yes   No  

	
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.
	
Who does this boat belong to?
Agency – check one
 WCCC    SMCC    CBITD   WELLS  NOTE: if MMA do not use this form!
Departmental Bureau
DOT		DMR		DEP		IFW		ACF
 MFS		 BMP	 BRMW	 BWS	 AWW
 M&O	 BMS	 BLWQ	 BRMF	 GEO
		 BPH				 BRMW	 BOATING
						 BRMH	 BPL
						 BRMW	 FORESTRY	
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: