BOAT/WATERCRAFT   INSURANCE  QUOTE

    
Personal Information
Name: 
Address: 
City:    State:    Zip: 
Day Phone:    Night Phone: 
Best Time To Call:    AM  PM
Email Address: 
Current Boat/Watercraft Insurance Information
Company Name (not agency):
Policy Expiration Date:    Premium Amount: $ 
Term: 6 Months  1 Year  Other: 
Coverages
(input only for those desired)
Type
Sums Insured
Type
Sums Insured
Hull-Physical Damage 
 $
Tender / Dinghy 
 $
Liability Coverage 
 $
Crew Liability 
 $
Owner / Operator M&C 
 $
Medical Payments 
 $
Comm. Passenger Liability 
 $
Uninsured Boater 
 $
Trailer 
 $
Personal Property 
 $
Non-Emergency Towing 
 $
Other 
 $
Vessel Information
Vessel Name:
Manufacturer/Model:
Year
Length
Date Purchased
Price $
Present Value $
Bilge Pumps 
CO2/Halon System 
Aux Generator, Diesel 
EPIRB 
Fume Detector 
Aux Generator, Gas 
Sonar 
Fire Extinguishers 
Other (list below) 
Depth Sounder 
Cooking Stove 
LORAN/Dir. Finder 
Engine Alarm 
GPS 
Anti-Theft Devices 
Radar 
Life Raft 
SATNAV/OMEGA 
Ship to Shore Radio 
Miscellaneous
(please check ALL that apply)
Primary Power
Type of Hull
Hull Material
Fuel Tank
Sail
Sailboat
Wood
Metal
Outboard
Performance
Metal
Fiberglass
Inboard
Runabout
Fiberglass
Inboard/ Outdrive
Other
Engine/Outboard Motor Information
(please complete for each engine)
Eng
H.P.
Gas
Diesel
Year
Date
Purchased
Purchase
Price
Present Value
1
$
$
2
$
$
3
$
$
Manufacturer/Model Serial Number
1
2
3
Trailer Information
Year
Date Purchased
Purchase Price
$
Present Value
$
Manufacturer/Model:
Serial #:
Operators
(always list insured as Operator #1) 
 # 
Name
DOB
Auto DL #
State
Social Security #
USCG/Power Squadron
Certificate
1
2
n/a
3
n/a
#
Auto Violations/Suspensions in last 5 years:
Years of Boat Ownership:
1
2
3
Boat/Watercraft Usage
 # 
Explain all YES responses in REMARKS Yes/No
 # 
Explain all YES responses in REMARKS Yes/No
1
Is the boat chartered to others with captain? Y
N
6
Is the boat used commercially or for business purposes? Y
N
2
Is the boat chartered to others without
captain?		 Y
N
7
Does the applicant employ a paid crew? If so how many? Y
N
3
Is the boat used for racing? Y
N
8
Was any operator involved in a marine loss in the last 10 years (insured or not)? Y
N
4
Is the boat used for water skiing or diving? Y
N
9
Was any coverage declined, cancelled or non-renewed during the last 5 years? Y
N
5
If the boat is used for fare paying passenger charters, what is the average number of passengers
per trip?      Number of trips per year? 
Additional Comments
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