Operator Resume

Operators Resume of Experience & Medical History

* Indicates required field

Name of Operator *

Date of Birth *

Address *

Married? *

Homeowner? *

City *

State *

Zip *

Phone # *

Email *

Employer *

Drivers License Number *

State *

Occupation *

Licensed Captain? *

Tonnage *

# of Years Licensed *

Prior boats you have OWNED and/or OPERATED: COMPLETE ALL CATEGORIES

Other *

Please list all marine incidents you have been involved with; including vessels damaged or passengers, crew or other third parties injured while you were acting as captain in the past five years (If none, write “None”): *

Please list all automobile infractions you have been involved with; including accidents, tickets and restrictions within the past three years (If none, write “None”): *

Have you ever been convicted of a felony? *

If yes, please advise date, the event and penalty: *

Have you undergone surgery in the past five years? *

If yes, please advise date and type of surgery: *

Have you been injured on the job in the past? *

If yes, please advise date of injury and disposition of claim: *

List all marine insurance claims and/or prior marine loss history in past 5 years (If none, write “None”): *

I HEREBY AFFIRM THAT ALL STATEMENTS MADE HEREIN HAVE BEEN ANSWERED TO THE BEST OF MY ABILITY AND ARE TRUE.

Name of person completing *

Date *

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Operator Resume

Operators Resume of Experience & Medical History

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