PASSENGER VESSEL INSURANCE APPLICATION …

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3455 East Paris SE, Grand Rapids, MI 49512 (616) (800) FAX (616) Website: E-mail Address: PASSENGER VESSEL INSURANCE APPLICATION . PERSONAL information . REGISTERED OWNER OR LEASEE NAME(S) DOING BUSINESS AS MARITAL STATUS RESIDENCE. MARRIED SINGLE OWNED RENTED. PHYSICAL ADDRESS CITY STATE ZIP. MAILING ADDRESS (IF DIFFERENT THAN PHYSICAL ADDRESS) CITY STATE ZIP. HOME PHONE CELL PHONE FAX NUMBER EMAIL ADDRESS. DRIVERS LIC. NO. DATE OF BIRTH OCCUPATION #. WATERCRAFT / TRAILER / DINGHY information . CRUISER / MOTOR YACHT SAILBOAT FLATS SKIFF BASS BOAT DRIFT BOAT CENTER CONSOLE. TYPE OF VESSEL SPORTFISH PONTOON AIRBOAT OPEN FISHING TRAWLER RUNABOUT. YEAR LENGTH MANUFACTURER MODEL HULL MATERIAL BEAM WEIGHT. NAME OF YACHT NO. HULL NO. PURCHASE DATE PURCHASE PRICE NEW REPLACEMENT COST DATE OF LAST SURVEY.

continued page 2 clakes app_charter rev. 02/14 general information has any named insured ever been convicted of a felony? yes (please explain below) no

  Information, Applications, Insurance, Vessel, Passenger, Passenger vessel insurance application