Owner/Operator Information List all operators of boat (including minor and occasional operators).
Operator's name Birth Date Years
experience
% use Driver's license no. & state
1. //
2. //
3. //
4. //
Have you (or the principal operator listed above) completed any boat safety courses offered by the following organizations? (Check if applicable)
US Power Squadron US Coast Guard Other:
Previous Boats owned/operated (specify size/type/years owned) Previous/current insurance company
Boating losses (Date, operator name, description, amount) Has insurance ever been canceled or declined? (Not applicable in MO)
Criminal Convictions (arson, burglary) within the past 5 years? Applicant's occupation
Previously declined, canceled, nonrenewed?
Brokered? No Yes
No Yes (if yes explain in remarks)
%
Is this boat used for racing? No Yes If yes, what % of time?
General Information
1. Motor vehicle accidents and/or convictions in past 3 years.
(Describe Date, Amount, Type, in Remarks)
2. Do you use the boat for water skiing?
No Yes, what percentage of time? ________ %
Remarks
Loss Payee
Loss Payee Name Alternate Payor
Address Address
City State Zip Code City State Zip Code
Additional Insured
Name Address City State Zip Code
To be completed by Agent
1. Account Bill 2. How many years have you
known the applicant?
3. Do you handle other insurance for the applicant
Yes No Yes
with Travelers Please list all policy numbers
Account # _____________________
Signature
The statements made on this application are accurate to the best of my knowledge. I agree that this application shall
constitute a part of any policy issued whether attached or not. I understand that any false or inaccurate information may
result in my policy being made null and void or canceled as permitted by state law. I also understand that any person
who, with intent to defraud or knowing that he or she is facilitating a fraud against an insurer, submits an application or
files a claim containing a false or deceptive statement may be guilty of insurance fraud.
Signature of Applicant: Date:
To the best of my knowledge, the applicant has provided truthful information and I certify that the above signature is
that of the named insured.
Signature of Agent: Date:
44203 Rev. 10-03 Back
