We would like to provide you
with a free, no-obligation boat/watercraft insurance quote. Please
provide as much information possible for the most accurate quote. This
information will be kept confidential and will be used for quote purposes
only.
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
$
Commercial Passenger Liability
$
Uninsured Boater
$
Trailer
$
Personal Property
$
Non-Emergency Towing
$
Other
$
Vessel Information
Vessel Name:
Manufacturer/Model:
Year
Length
Date
Purchased
Purchase
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/ Direction 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?
REMARKS
Additional Comments
Please give any additional comments you feel appropriate
for this quotation. If you have additional information where there was
not enough fields above, such as additional operators, coverages, etc...,
please enter them here.
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your quote request.
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