Wilson, Washburn & Forster

Personal Marine Insurance Quote

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.

General Info
* Name:
Address:
City:
State:
Zip Code:
Home Phone:
Cell Phone:
* Email Address:
Best Time To Contact:
Contact By:

Current Policy Information
Agent:
Address:
City:
Policy Expiration Date:

Coverage(s) Information
Hull:	$
Liability Coverage:	$
Owner/Operator M&C:	$
Commercial Passenger Liability:	$
Trailer:	$
Uninsured Boater:	$
Personal Property:	$
Medical Payment:	$
Non-Emergency Towing:	$

Vessel Information
Vessel Name:
Manufacturer Model:
Hull Indentification No.:
Year:
Length:
Date Purchased:
Purchase Price:	$
Present Value:	$
Max Speed:	mph
Registration No.:

Engine Information
	Engine 1	Engine 2
Horsepower:
Gas/Diesel:
Inboard/Outboard I/O:
Manufacturer:
Serial:
Location of Vessel:
Tenders/Dinghies:
Waters Navigated:

Boat/Watercraft Equipment
Bilge Pumps:
CO2/Halon System:
Aux Generator, Diesel:
Aux Generator, Gas:
EPIRB:
Fume Detector:
Sonar/Radar:
Fire Extinguishers:
Depth Sounder:
LORAN:
Engine Alarm:
GPS:
Anti-Theft Devices:
Stereo System:
Life Raft:
SATNAV:
Ship to Shore Radio:
Other Equipment:

Miscellaneous
Primary Power:
Type of Hull:
Hull Material:
Fuel Tank:

Driver/Operator Information
	Driver 1	Driver 2
Name:
DOB:
Auto DL#:
State:
USCG/Power Squadran Certificate
Years of Boat Ownership:
Auto Violations/Suspensions in Last 5 Years:

Trailer Information
Year:
Date Purchased:
Purchase Price:
Present Value:
Manufacturer/Model
Serial #:

Boat/Watercraft Usage
Is boat a charter boat:
Is boat used commercially?:
Is boat used for racing?:
Will you be water skiing or diving with your boat?:
If you boat is used for charters, what is the average number of passengers and trips?:	per trip?: trips per year?:
If boat is used commercially, is there crew?:
Was any operator involved in a marine loss in the last 10 years (insured or not)?:
Was any coverage declined, cancelled or non-renewed during the last 5 years?
Additional Explanations:

Additional Information 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.