JET SKI APPLICATION:  
  All fields should be completed. If a field does not apply insert "NONE".
About the Owner  
 
Name of Registered Owners:
Residential Address:
City:
State:
Zip:
Phone:
Alternate Phone:
Fax Number:
Email Address:
 
Liability:
 
About the Personal Watercraft  
 
Model Year:
Model Length:
Manufacturer:
Model:
Engine CC's:
Purchase Date:
Purchase Price:
Current Value:
Designed Passenger Capability:
1 2 3 4
Storage Location:

(If left blank we will assume that the storage location is the same as your residence as listed above)

 
Trailer: If no Trailer, check here.
 
Year of Trailer:
Manufacturer of Trailer:
Current Market Value:
 

About the Operator(s):
(All Operators must be at least 16 years old with a valid U. S. drivers licenses)

 
Operator No. 1  
 
Name:
Date of Birth:
Years as Operator of PWC:
 
Operator No. 2 If no Operator No. 2, check here.
 
Name:
Date of Birth:
Years as Operator of PWC:
 
Operator No. 3 If no Operator No. 3, check here.
 
Name:
Date of Birth:
Years as Operator of PWC:
 
Operator No. 4 If no Operator No. 4, check here.
 
Name:
Date of Birth:
Years as Operator of PWC:
 
Navigation  
 

Describe the navigation area that specifically meets your needs:

 
 
Lienholder
Yes No
 
 
Lienholder Name:
Street Address:
City:
State:
Zip:
 
Current Insurance Information:  
 
Do You Currently Have Insurance?
Yes No
Company:
Renewal Date:
Any Insurance Cancelled, Declined or Non-Renewed:
Yes No
If so, detail reason:
 

Will subject watercraft be rented or used for any commercial purpose?

 
Yes No
If so, detail reason:
 

Will the subject watercraft be operated by a captain or a crew who receives money or other benefits from you?

 
Yes No
If so, detail reason:
 

Does the watercraft have any deficiencies or unrepaired damage?

 
Yes No
If so, detail reason:
 

Is the watercraft owned in whole or in part by anyone other than the titled owner as listed above? (excluding a lienholder)?

 
Yes No
If so, detail reason:
 

Is the watercraft ever stored in a public parking area such as an apartment house parking lot?

 
Yes No
If so, detail reason:
 

Have there been any claims, accidents or losses to boats or from marine liability within the last three years?

 
Yes No
If so, detail reason:
 

Was there a lapse in insurance coverage for more than 30 days just before answering this question?

 
Yes No
If so, detail reason:
 

Have you or any regular operator ever been convicted of or pleaded no contest to a felony?

 
Yes No
If so, detail reason:
 
Has any operator:  
 
a.

been charged with operating a boat or motor vehicle under the influence of drugs or alcohol

  
Yes No
b.

been charged with reckless or careless driving

  
Yes No
c.

had more than 2 moving violations within the last 36 months

  
Yes No
 
 

Any special comments, questions or instructions be sure to let us know.

 
   
   
 
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March 11, 2010   
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