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$Medical Payments$
Commercial Passenger Liability$Uninsured Boater$
Trailer$Personal Property$
Non-Emergency Towing$Other$
Vessel Information
Vessel NameManufacturer/Model
YearLengthDate
Purchased
Purchase
Price
Present
Value
Max
Speed
Registration#
$$mph
Hull Identification #Waters to be navigated:
Tenders or DinghiesStorage Address (Street, City, Co., St.)

Stored on TrailerLaid Up
Y   NFrom: to
Will be trailered over 100 miles:Location
Y   NOn Shore Afloat
Equipment
(please select ALL equipment on your Boat/Watercraft)
Bilge PumpsCO2/Halon SystemAux Generator, Diesel
EPIRBFume DetectorAux Generator, Gas
SonarFire Extinguishers
Other (list below)
Depth SounderCooking Stove
LORAN/ Direction FinderEngine Alarm
GPSAnti-theft Devices
RadarLife Raft
SATNAV/ OMEGAShip to Shore Radio
Miscellaneous
(please check ALL that apply)
Primary Power
Type of Hull
Hull Material
Fuel Tank
SailSailboatWoodMetal
OutboardPerformanceMetalFiberglass
InboardRunaboutFiberglass
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/ModelSerial 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 REMARKSYes/No
 # 
Explain all YES responses in REMARKSYes/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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