COMPANY NAME __________________________________________________
ADDRESS ______________________________________________________________________
CITY ______________________________________________________________________
E-MAIL ______________________________________________________________________
PHONE NUMBER ______________________________________________________________________
MARINE GENERAL LIABILITY ( ) $2,000,000 ( ) $1,000,000 ( ) $500,000 ( ) $300,000
DOES THE COMPANY OWN A MARINA?_______. TOTAL SALES $ ____________________
INDICATE MARINE ARTISAN TRADES OR SMALL MARINE CONTACTOR TRADES
( ) MARINE VALVE WORK ( ) MARINE WELDING ( ) BEACH RESTORATION
( ) MARINE CARPENTRY ( ) OUTFITTING ( ) BOAT & TRAVEL LIFT INSTALLATION REPAIR
( ) MARINE ELECTRONICS ( ) PROP REPAIR ( ) DOCK & GANGWAY CONSTRUCTION & REPAIR
( ) MARINE ENGINE REPAIR ( ) SAIL CANVASS REP ( ) DREDGING
( ) MARINE REFRIGERATION & PLUMBING ( ) MARINE OUTFLOW TUNNEL \
( ) MARINE RIGGING WORK ( ) SHRINK WRAPPING ( ) MARINE PILE DRIVING /COFFERDAMS
( ) MARINE WELDING ( ) SODA BLASTING ( ) SEAWALL/BREAKWATER CONSTRUCTION-REP
( ) VESSEL COMMISSIONING ( ) VESSEL PAINTING ( ) VESSEL SALVAGE
( ) WINTERIZATION. ( ) WHARF CONSTRUCTION
PROPERTY ( ) BUILDING LIMIT $_____________ ( ) CONTENTS $____________ ( ) TOOLS $____________ OTHER ___________________
BUSINESS AUTO ( ) $2,000,000 ( ) $1,000,000. ( ) $500,000. ( ) $ 300,000
Year Make Model VIN (17 DIGITS) COMPREHENSIVE COLLISION DEDUCTIBLE
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NAME DATE OF BIRTH DRIVERS LICENSE STATE
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WORKERS COMPENSATION CLASS/TYPE OF WORK _____________ REMUNERATION________________________FED TAX ID ______________________