Contact Information

Name*
Address
City*		State*	Select Pennsylvania	Zip:

Please supply either a Daytime or Evening Phone Number and the best time to call.
Day Time Number:
Evening Number: (570)
Best Time To Call*	Select Morning Afternoon Evening
E-mail:*

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Marital Status:	Single Married Divorced Separated Widowed
Current insurance carrier* (If you do not have a current insurance carrier type in NONE)
How Long*	years
Policy Expiration Date

Number of years experience

Member of any boating association

Yes No

Purchase price:

Loss Payee

Has insurance ever been declined:

Yes No

If Yes,

explain

List and detail any losses or claims

Watercraft Information

Year:

Length:

Model:

Builder:

Hull Identification #:

Name of Boat:

Hull Type

Cruiser Trawler Sail Houseboat Runabout Personal Watercraft

Hull Material

Fiber Glass Wood Other

If other,

Engine

Gas Diesel Inboard Outdrive/I/O Outboard Jet Drive

Year:

Manufacturer:

How many:

HP each:

Max Speed (MPH):

Engine(s) S#:

Trailer

Year:

Length:

Manufacturer:

S#:

Tender

Year:

Length:

Manufacturer:

S#:

Tender's Motor

Year:

Length:

Manufacturer:

S#:

Equipment

Loran	Yes No	Radar	Yes No	Halon	Yes No
GPS	Yes No	Depth Finder	Yes No	VHF	Yes No

Other:

Navigation

Chesapeake Bay Trib.

Yes No

Inland Water

Yes No

Specify Waters

Atlantic Coast between

and

Vessel will be laid up

Ashore Afloat

Where:

Vessel in excess of 24' ONLY Ever transported overland

yes no

if yes, how many miles?

Chartered

Yes No

Ever used for water skiing?

Yes No

Coverage

Effective Period From

to

	VALUES	DEDUCTIBLE	PREMIUM
Hull and Machinery
Outboard Motor
Equipment
Tender and its Motor
Trailer
Liability
Medical Payments
Overland Transp. (miles)
Uninsured Boaters
Personal Effects
Assistance/Towing
Total Premium

Additional Information:

NOTE: All asterisked* fields must be completed for a successful submission. Thanks!

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Paciotti Insurance
320 Main St
Dickson City, PA 18519
(570) 383-3030