Joseph H. McGlone, Inc.
Insurance Analyst

Customer Information

   

Please choose:	Mr.,Mrs.,or Ms. Mr. Mrs. Ms.
Last name:		First name:
Address:
City, State, Zip:
E-mail address:
Home phone:		Work phone:

 

Information about Boat

Boat:      make       model       length                                    year                 value

 

Type of  boat:     sail         power          ( if  power)  Select inboard inboard twin outboard outboard twin inboard/outboard I/O twin other

 

Engine:   make        model          horsepower                   mfg. recommended max MPH.    value (outboard)

 

Electronics on board:   radio         depth finder        gps                                             Loran        radar       other

 

Used on: Select Inland lakes Atlantic coastal Chesapeake Bay Florida (East coast) Gulf of Mexico other          Used for: Select pleasure charter                            if used for charter approx. how many times annually                                do individuals chartering also operate boat - yes   no

 

Boat is used in water from:   January February March April May June July August September October November December   through  January February March April May June July August September October November December

 

Do you plan to navigate this boat beyond the coastal waters of the U.S.?  - yes    no                      If "yes", to:      Bermuda   Caribbean   Canada   Mexico   other

 

During boating season boat is:  - hauled on trailer    (if trailer is used) what                                                        is the model and value                                                     -  moored at dock ,  in boathouse ,  other

 

During off season the boat is:         on trailer at residence                                                           on trailer not at residence                                                            dry storage in boatyard                                                           wet storage with bubblier system                                                           wet storage, no bubblier system

 

Operator Information

List all operators of boat (including minors)

	Operator # 1	Operator # 2	Operator # 3	Operator # 4
Full name:
Date of birth:
Years boating exp:
percent of  use:
completed USPS/USCGA boating courses	yes no	yesno	yesno	yesno

Has any operator sustained any boat losses, automobile moving violations or accidents during the past 3 years?  no    yes   (if yes list details below - include: date, amount, type of violation, cause, operator, etc.):