Bardstown Insurance Kentucky

Personal Information
Your Name:			Effective Date:
Street Address:			City:
State:			Zip Code:
Email Address:			Phone Number:
	Call me with the quote			Email me the quote
Description of Property
Motor Type:			Number of Engines:
Boat Type:			Other Boat Type:
Fuel:			Maximum Speed:
Hull Type:			Other Hull Material:
Insured Watercraft
Boat:
Year:			Manufacturer:
Model:			Serial Number:
Length:			Total HP:
Outboard Motor:
Year:			Manufacturer:
Model:			Serial Number:
Total HP:
Trailer:
Year:			Manufacturer:
Serial Number:
Coverages & Limits
Boat (including auxiliary equipment, please break down o/b information):			Boat Trailer:
Outboard Motor 1 (ACV Coverage):			Outboard Motor 2 (ACV Coverage):
Personal Property ($500 automatic):			Commercial Towing ($400 automatic):
Boat Liability (ACV Coverage):			Medical Payments ($1,000 automatic with liability):
Uninsured Boater:
Optional Coverages Agreed Value Endorsement Actual Cash Valule Fishing Equipment - Limit
Safety Equipment
GPS	Yes No		Radar	Yes No
Automatic CO2 (Halon)	Yes No		Plotter	Yes No
Ship to Shore Radio (VHF)	Yes No		EPIRB	Yes No
Depth Sounder	Yes No		Vapor Detector Alarm	Yes No
Electronic Burglar Alarm	Yes No
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
Additional Comments
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