Name:
Date of Birth:
Phone*:
Email*:
Address:
City:
Zip:
Driver's License #:
Occupation:
State where boat is stored * :
Years of boating experience * :
Boat Length * :
Maximum Speed * :
How many motor would you like to insure?* 123
Year :
Trade Name :
Model :
Horse Power :
Value :
Comments:
Acknowledgement: I understand no coverage is bound until confirmed in writing by a KM agent
Name (type):
Date
Signature