| * Indicates
a Required Field
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|
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| First Name
|
*
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|
| Middle
Initial
|
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| Last Name
|
*
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| Telephone
|
(O) *
|
Enter in (xxx) xxx-xxxx format
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|
(H) *
|
Enter in (xxx) xxx-xxxx format
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| Address
|
*
|
Important: Enter an
address that can be used to obtain additional information.
|
| Suite/Apt
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| City
|
*
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| State
|
*
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| Zip Code
|
*
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| E-mail
|
* |
E-mail is the preferred means of
communications.
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| Manufacturer Name
|
*
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| Model Year
|
*
|
Record 'Model Year' in 'yyyy' format
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| Model Name
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| Hull ID
|
|
Hull Identification Number:
Twelve character manufacturer serial number on outboard starboard side of
transom; also shown on the State registration certificate
|
| Length
|
Feet
Inches
*
|
| Type
|
*
|
| Date Purchased
|
|
Record 'Date Purchased' in 'mm/dd/yyyy'
format.
|
| Dealer's Name
and Address
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| Boat Condition |
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| Boat
Use |
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|
|
*
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| Is defect being reported associated
with the engine?
|
|
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| Engine and Drive
Manufacturer
|
*
|
|
| Model Year
|
*
|
Record 'Model Year' in the 'yyyy' format.
|
| Model Name or
Number
|
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|
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|
If other, please specify:
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| Defect resulted in accident?
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| Number of Injuries
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| Number of Fatalities
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| Estimated Property
Damage
|
|
Record in the $xx.xx format.
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| Accident Date
|
|
Record 'Accident Date' in 'mm/dd/yyyy'
format
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| Accident Location
|
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| Name(s) of Deceased
|
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| Age(s) of the
Deceased
|
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| Description of the Accident /
Incident
|
|
|
|
|
Please mail copies
of any correspondence, repair orders, invoices, marine surveys,
photos or sketches that you feel could substantiate the existence
of a safety defect. If the possible safety defect is in a component
installed or modified by someone other than the boat manufacturer,
please so indicate and give details. Mailing address:
Office of Boating Safety Product Assurance Division (G-OPB-3)
United States Coast Guard
2100 Second Street SW
Washington, DC 20593-0001
|
| Defect Information
(Why do you think the boat or component is defective? What part
of the boat or component is defective?)
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| Provide additional information
that may be helpful to the Coast Guard in deciding whether or not
this is a safety related defect
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