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. 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 Name: Manufacturer/Model:   Year   Length Date Purchased Purchase Price $ Present Value $ Max Speed mph   Registration # Hull Identification #: Waters to be navigated: Tenders or Dinghies: Storage Address (Street, City, Co., St.): LAID UP: From: to On Shore Afloat Stored on Trailer: Y   N Will be trailered over 100 miles: Y   N   Equipment (please select ALL equipment on your Boat/Watercraft) Bilge Pumps CO2/Halon System Aux Generator, Diesel EPIRB Fume Detector Aux Generator, Gas Sonar Fire Extinguishers Other (list below) Depth Sounder Cooking Stove LORAN/ Direction Finder Engine Alarm GPS Anti-theft Devices Radar Life Raft SATNAV/ OMEGA 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               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/Model Serial 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 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. Please click on the "Submit Quote" button to send your quote request. One of our representatives will respond to your submission as soon as possible.