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.

Personal Marine Insurance Quote

General Info

Name(required)

Address

City

State

Zip Code

Home Phone(required)

Cell Phone

Email address(required)

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

Horsepower

Horsepower 2

Gas/Diesel

Gas/Diesel 2

Inboard/Outboard I/O

Inboard/Outboard I/O 2

Manufacturer

Manufacturer 2

Serial

Serial 2

Location of Vessel

Location of Vessel 2

Tenders/Dinghies

Tenders/Dinghies 2

Waters Navigated

Waters Navigated 2

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

UntitledUSCG/Power Squadran Certificate

USCG/Power Squadran....

Years of Boat Ownership

UntitledAuto Violations/Suspensions in Last 5 Years

Auto Violations/Suspensions....

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 your 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.

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Personal Marine Insurance Quote

Personal Marine Insurance Quote

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