We are glad to provide you with a free, no-obligation boat/watercraft insurance quote.
Please provide as much information as possible for the most accurate quote.
This information will remain confidential and will be used for insurance quote
purposes only.


Name    Address

City    State     Zip

Daytime phone     Best time to call    AM    PM 

eMail

Occupation     For how long?


Company name     Policy expiration

Premium amount $    Term


TYPE

 SUMS INSURED TYPE SUMS INSURED
Hull - Physical damage $ Tender/Dingy $
Liability coverage $ Crew Liability $
Owner/Operator M&C $ Medical payments $
Commercial passenger $ Uninsured boater $
Trailer $ Personal property $
Non-emergency towing $ Other $


Vessel name     Manufacturer

Year     Length     Date of purchase     Model

Purchase price $     Present value     Max speed

Registration #    Hull ID#

Waters to be navigated

Tenders     Dingies     Stored on trailer     Will be trailered over 100 miles

Storage address     City     State

Zip

Laid up from to     On-shore     Afloat



Please select all equipment on your boat/watercraft

Bilge pump Fume detector Other (listed below)
EPIRB Fire extinguisher
Sonar Cooking stove
Depth sounder Engine alarm
LORAN/Direction Finder Anti-theft devices
GPS Life raft
Radar Ship-to-shore radio
SATNAV/OMEGA Aux generator, diesel
CO2/Halon Aux generator, gas



Check all that apply

PRIMARY POWER TYPE OF HULL HULL MATERIAL FUEL TANK
Sail Sailboat Wood Metal
Outboard Performance Metal Fiberglass
Inboard Runabout Fiberglass Plastic
Inboard/Outdrive Pontoon    
Other      



Please complete for each engine

ENGINE 1
Horsepower     Gas     Diesel     Year     Purchase date
Purchase price $     Present value $
Manufacturer     Model
 
ENGINE 2
Horsepower     Gas     Diesel     Year     Purchase date
Purchase price $     Present value $
Manufacturer     Model
 
ENGINE 3
Horsepower     Gas     Diesel     Year     Purchase date
Purchase price $     Present value $
Manufacturer     Model


Year     Date purchased    Purchase price $

Present value $

Manufacturer     Model

Serial #



Always list insured as Operator 1

OPERATOR 1
Name     Date of birth     Auto D.L#
State     SS#     Years boat ownership
Auto violations/suspension in past 5 years
USCG/Power Squadron certificate
 
OPERATOR 2
Name     Date of birth     Auto D.L#
State     SS#     Years boat ownership
Auto violations/suspension in past 5 years
USCG/Power Squadron certificate
 
OPERATOR 3
Name     Date of birth     Auto D.L#
State     SS#     Years boat ownership
Auto violations/suspension in past 5 years
USCG/Power Squadron certificate



Explain all yes responses in remarks

  YES NO
1. Is the boat chartered to others with captain?
2. Is the boat chartered to others without captain?
3. Is the boat used for racing?
4. Is the boat used for water skiing or diving?
5. Is the boat used commercially or for business purposes?
6. Does the applicant employ a paid crew? (If yes, how many?)
 
7. Any operator involved in a marine loss in the last 10 years? (Insured or not)
8. Any coverage denied, cancelled or not renewed during the past 5 years?
9. If used for fare paying passenger charters, what's the avg. passengers per trip?
10. If used for fare paying passenger charters, what's the avg. passengers per year?
Remarks
    


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