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Personal
Information
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| Please
give us your Name: First
Initial Last
|
| Home
Address
Apt. |
| City
State
Zip Code |
| Home
Phone Number (
)
Work Number (
)
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|
Email: Enter
Email again:
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| Marital
Status |
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Drivers License No.
Social
Security No. |
| Birth
Date / / (4
digit year) Gender
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Are you certified?
If
yes, what type?
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Insurance
Information
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Have you ever previously had boat insurance?
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Are you currently insured for boat insurance?
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If
yes, how many years with your present insurance company?
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When
does your insurance expire with your present
company?
Month:
Day: Year:
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Have
you ever made a boat claim? (If
yes, explain in comments below)
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Any driving violations in the past 5 years? (If
yes, explain below)
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Boat
Information
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| What
is the intended use of the boat?
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Where
will you use this boat?
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Year:
(enter 4 digit year)
Hull Type:
Boat Type:
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Manufacturer:
Model:
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Engine
Information
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Number
of Engines: Horsepower
Each Engine:
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Engine
Type:
Fuel
Type:
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Equipment
Information
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|
Please check all that apply:
VHF
Depth
Loran
Compass
Radar
GPS
EPIRB
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Fume
Detector:
|
Fire Equipment Type:
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Additional
Insurance
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|
Please
check all that you wish to add or receive
information:
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Comments
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Clicking
Submit will forward your responses.
A
Glades Insurance Representative will contact you
shortly.
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