BOAT / WATERCRAFT INSURANCE QUOTE 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. This form is hosted on a secure server using SSL technology.

 

Personal Information Primary Insured's Name (First, Last): Date of Birth: Primary Insured's Occupation: How long at current job: Highest level edu. completed Spouse's Name (First, Last): Date of Birth: Spouse's Occupation: How long at current job: Highest level edu. completed Physical Address: City:   State:   Zip: Is the mailing address the same as the physical address? Y N Mailing Address: City:   State:   Zip: Day Phone:   Night Phone: Best Time To Call:   AM   PM Email Address:  Do you rent or own your home?: Rent   Own

How Did You Hear About Us? Please check all that apply: Search Engine Social Network Advertisement Family or Friend Forum/Blog Co-Worker Other:

Current Boat/Watercraft Insurance Information Company Name (not agency): Policy Expiration Date:   Premium Amount: $ Term: 6 Months   1 Year   Other:

Coverages (input or select only for those desired) Type Sums Insured Type Sums Insured Hull Physical Damage Deductible - Select - $   500.00 $1,000.00 $2,000.00 $5,000.00 Uninsured Boater - Select - $100,000.00 $300,000.00 $500,000.00 Liability Coverage - Select - $100,000.00 $300,000.00 $500,000.00 Personal Property $ Trailer Value $ Other $

Vessel Information Vessel Name Manufacturer/Model   Year   Length Date Purchased Purchase Price Present Value Max Speed   Registration# $ $ mph Hull Identification # Waters to be navigated: Stored on Trailer Storage Address (Street, City, Co., St.) Y   N Will be trailered over 100 miles: Laid Up Y   N From: to Location On Shore Afloat

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 Year Make Model Value 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 USCG/Power Squadron Certificate 1 2 3 # 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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