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FLORIDA FISH AND WILDLIFE

CONSERVATION COMMISSION

Livery Insurance Coverage Option for Renter

FWCDLE_319 (10/23) – Rule 68D-34.006, F.A.C.


I UNDERSTAND THAT I AM REFUSING TO PURCHASE A VESSEL RENTAL INSURANCE POLICY FOR COVERAGE OF AT LEAST $500,000 PER PERSON AND $1 MILLION PER EVENT FOR ANY DAMAGE OR INJURIES CAUSED DIRECTLY OR INDIRECTLY BY MY OPERATION OF THE VESSEL.

I Agree


I UNDERSTAND THAT I MAY NOT HAVE OTHER INSURANCE TO COVER ANY DAMAGE OR INJURIES CAUSED DIRECTLY OR INDIRECTLY BY MY OPERATION OF THE VESSEL AND THAT I MAY BE PERSONALLY LIABLE FOR ANY SUCH DAMAGE OR INJURIES DURING THE RENTAL PERIOD.


I Agree






THE VESSEL RENTAL INSURANCE POLICY COVERAGE IS BEING OFFERED TO ME AT THE FOLLOWING PRICE:
ENTER QUOTE AMOUNT *
Boater Safety Card
The renter Does or Does Not have a Florida boater safety identification card issued by the commission, a temporary certificate, or another form of boating certification authorized pursuant to s. 327.395*
Does
Does Not
First Participant's Name
First Name*
Last Name*
First Participant's Date of Birth*
Date of Birth
First Participant's Signature*
Second Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Third Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Fourth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Fifth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Sixth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Seventh Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Eighth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Ninth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Tenth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Parent or Guardian's Email Address
Email*
Confirm Email*
Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Last Name*
Phone*
Parent or Guardian's Date of Birth*
Date of Birth
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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