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Personal information

Name *

Address

Phone number *

Email *

Date of birth

Driver's license number

Occupation

Boat information

State where boat is stored

Years of boating experience

Boat type

InboardInboard/OutboardInboard waterjetOutboardPersonal watercraftSail

Boat length

feet

Maximum speed

miles per hour

Hull

Year

Trade name

Model

Horsepower

Value ($)

Motor

Year

Trade name

Horsepower

Value ($)

Trailer

Year

Trade name

Value ($)

Comments

Comments

Binding Agreement

I understand that for my protection, coverage cannot be bound, changed or confirmed via this online request, and that I must speak directly with a licensed representative of Insurance Network of Louisiana.

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