TITLED OWNER	TEL#	LIST ALL OPERATORS

MOTOR VEHICLE RECORD CLEAN?	DATE AND DESCRIPTION OF ANY ACCIDENT/VIOLATION
YES NO

YEAR.	MFG.	MODEL#	LENGTH	PURCHASE PRICE AND DATE

HULL CONSTRUCTION  FIBERGLASS WOOD METAL

# OF MOTORS	HP PER MOTOR
		GASDIESELMOTOR TYPE: I I/OO3

LIMITS OF INSURANCE:
$	WATERCRAFT & EQUIPMENT - DEDUCTIBLES	2% (MIN. $250) 5% (MIN. $500)
$	WATERCRAFT LIABILITY ($10,000-$50,000-$100,000-$300,000-$500,000)
$	WATERCRAFT  LIABILITY (IF REQUESTED - MUST MATCH WATERCRAFT LIABILITY)
$	MEDICAL PAYMENTS (MAX. $5,000)
$	UNINSURED BOATERS ($10,000-$50,000-$100,000-$300,000-$500,000)
$	DINGHY TENDER AND ITS OUTBOARD MOTOR
$	PERSONAL EFFECTS (MAX. $5,000)
$	TRAILER
$	EMERGENCY WATERWAY SERVICES

EQUIPMENT: (PLEASE CHECK EACH APPLICABLE ITEM)
	HALON/CO2 AUTO SYSTEM	SMOKE DETECTOR	FIRE EXTINGUISHER(S)
	SHIP TO SHORE RADIO	FUME DETECTOR	DEPTH FINDER
	ELECTRIC ALARM	BILGE BLOWERS	OUTBOARD/OUTDRIVE LOCKS
	GPS SYSTEM	RFD	TRAILER HITCH/AXEL LOCKS
	COMPASS	PROPELLER/HUB LOCKS	LORAN
	RADAR	CHART PLOTTER	EPIRB

PRIMARY WATERS OF NAVIGATION	OTHER WATERS

CITY	STATE	WILL VESSELS BE USED FOR WATER-SKIING?
		YES NO

LAY-UP DATES

ASHORE IN WATER

WILL VESSEL BE USED FOR ANYTHING OTHER THAN PRIVATE PLEASURE?

YES NO

IF YES, DESCRIBE OTHER USAGE

PREVIOUS BOATS OWNED AND /OR OPERATED - INCLUDE LENGTH

# OF YEARS OPERATING ANY TYPE OF VESSEL

BOATING EDUCATION:	PS CGA YCOTHER

PAID CAPTAIN/CREW	YES NO

IS THIS VESSEL FOR SALE BY THIS APPLICANT?	YES NO

ANY WATERCRAFT LOSSES LAST (3) YEARS?	YES NO

IF YES, DESCRIBE (INCLUDE PAY-OUT):

EVER BEEN DECLINED, NON-RENEWED OR CANCELED?	YES NO

IF SO, WHY?

CURRENTLY INSURED WITH	PREMIUM PAYING	EXP. DATE

IF VESSEL IS OVER 10 YEARS OLD, DO YOU HAVE A SURVEY?	YES NO

IF YES, DATE OF SURVEY? (MO/DAY/YR)