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BOAT / WATERCRAFT INSURANCE QUOTE

Simply fill out the information below as thoroughly as possible and submit your application. It will be sent to us, in confidence, and we will process your information and contact you shortly with your quote.

Personal Information

Name: Email Address:
Address: Day Phone:
City: Night Phone:
State:   Zip: Best Time To Call:  

How did you hear about us?
If "Friend/Co-Worker", Name:
If "Other", please explain:

How would you like to receive your quote?
Fax Number:

Current Boat/Watercraft Insurance Information

Company Name (not agency):
Policy Expiration Date:
Premium Amount: $
Term: If Other:

Coverages

(input only for those desired)
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:

Waters to be navigated:

Manufacturer/Model: Year
Tenders or Dinghies:
Storage Address (Street, City, Co., St.):

Length
Date Purchased
Purchase Price $
Present Value $
Max Speed mph

Equipment

(please select ALL equipment on your Boat/Watercraft)
Bilge Pumps
EPIRB
Sonar
Depth Sounder
LORAN/ Direction Finder
GPS
Radar
SATNAV/ OMEGA
CO2/Halon System 		Fume Detector
Fire Extinguishers
Cooking Stove
Engine Alarm
Anti-theft Devices
Life Raft
Ship to Shore Radio
Aux Generator, Diesel
Aux Generator, Gas
 Other (list below)

Miscellaneous

(please check ALL that apply)
Primary Power
Sail
Outboard
Inboard
Inboard/ Outdrive
Other		 Type of Hull
 Sailboat
Performance
Runabout		 Hull Material
Wood
Metal
Fiberglass		 Fuel Tank
Metal
Fiberglass

Engine/Outboard Motor Information

(please complete for each engine)
Engine 1
H.P.     Fuel:     Year
Manufacturer/Model:
 
Engine 2
H.P.     Fuel:     Year
Manufacturer/Model:
 
Engine 3
H.P.     Fuel:     Year
Year
Manufacturer/Model:

Trailer Information

Year     Manufacturer/Model:
Date Purchased
Purchase Price $     Present Value $

Operators

(always list insured as Operator #1)

Operator 1

Name
Date of Birth
Auto DL # State
Social Security #
USCG/Power Squadron
Certificate #
 Years of Boat Ownership:
Auto Violations/Suspensions in last 5 years:
 

Operator 2

Name
Date of Birth
Auto DL # State
Social Security #
USCG/Power Squadron
Certificate #
 Years of Boat Ownership:
Auto Violations/Suspensions in last 5 years:
 

Operator 3

Name
Date of Birth
Auto DL # State
Social Security #
USCG/Power Squadron
Certificate #
 Years of Boat Ownership:
Auto Violations/Suspensions in last 5 years:

Boat/Watercraft Usage

Explain all CHECKED responses in REMARKS
Is the boat chartered to others with captain?
Is the boat used commercially or for business purposes?
Is the boat chartered to others without
captain?
Does the applicant employ a paid crew? If so how many?
Is the boat used for racing?
Was any operator involved in a marine loss in the last 10 years (insured or not)?
Is the boat used for water skiing or diving?
Was any coverage declined, cancelled or non-renewed during the last 5 years?
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:(explain all checked responses from above)

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.


One of our representatives will respond to your submission as soon as possible.



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