Personal Marine Quote Request

Please note that this form is for a REQUEST ONLY. By submitting this form it does not bind coverage in any way.  If you do not hear from us in a reasonable amount of time, ASSUME WE DID NOT GET THIS REQUEST FOR AN INSURANCE QUOTE, and call our office.

I understand that filling out and submitting this form DOES NOT bind coverage in any way, and the only way coverage can be bound will be when I am informed of a binder or policy is issued by the agent representing me. 

Information

Please be sure to complete all of the requested information so that your agent may contact you after receiving this notification.
Named Insured:
Address:
City:
State:
Zip:
Day Phone:    
Beeper:   
Eve. Phone:
Cell Phone:
E-mail Address:
Best Time To Contact:    AM   PM
Method of contact:

Current Policy Information
Agent:
Insurance Company:
Policy Number:
Policy Expiration Date:

Coverage's
 (input desired coverages)
Type Amounts
Hull $
Liability Coverage $
Owner / Operator M&C $
Commercial Passenger Liability $
Trailer $
Uninsured Boater $
Personal Property $
Medical Payments $
Non-Emergency Towing $

Vessel Information
Vessel Name (if any):
Manufacturer/Model:
Hull Identification #:
Year:
Length:
Date Purchased:
Purchase Price: $
Present Value: $
Max Speed: mph
Registration #
Engine 1  
H.P.
Gas/Diesel: GasDiesel
Inboard/Outboard I/O: InboardOutboard I/O
Manufacturer:
Serial:
Engine 2  
H.P.
Gas/Diesel: GasDiesel
Inboard/Outboard I/O: InboardOutboard I/O
Manufacturer:
Serial:
Engine 3  
H.P.
Gas/Diesel: GasDiesel
Inboard/Outboard I/O: InboardOutboard I/O
Manufacturer:
Serial:
Location of Vessel:
Tenders or Dinghies:
Waters navigated:

Boat/ Watercraft Equipment
 (please list  ALL equipment on your Boat/Watercraft. Use the other to list equipment not indicated)
Bilge Pumps CO2/Halon System Aux Generator, Diesel
EPIRB Fume Detector Aux Generator, Gas
Sonar/radar Fire Extinguishers Other (list below)
Depth Sounder Cooking Stove
LORAN Engine Alarm
GPS Anti-theft Devices
Stereo System Life Raft
SATNAV 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        

Trailer Information
Year:

Date Purchased:

Purchase Price: $
Present Value: $
Manufacturer/Model:
Serial #:

Operators
 #  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 EXPLANATIONS Section below.
1 Is the boat a charter boat? Y
N		 6 If boat is used commercially, is there crew? If so how many? (below) Y
N
2 Is the boat used commercially ? Y
N		 7 Was any operator involved in a marine loss in the last 10 years (insured or not)? Y
N
3 Is the boat used for racing? Y
N		 8 Was any coverage declined, cancelled or non-renewed during the last 5 years? Y
 N
4 Will you be  water skiing or diving with your boat? Y
N		      
5 If the boat is used for charters, what is the average number of passengers and trips.
per trip?     Number of trips per year?

EXPLANATIONS
 
Prior Owned Boats
 In the box below, please specify any previously owned boats and/or vessels

Additional Information Section
In the box below, please provide  any additional information  you feel may be necessary  for us to provide you with the best quote possible such as additional operators, coverages engines, etc.