Insurance Quote

Insurance Quote

CLOSING DATE/EFFECTIVE DATE:

NAMED INSURED (*)

Phone

Address (*)

City (*)

State (*)

Zip (*)

Email (*)

Occupation

Date of Birth (*)

Driver’s License #/State (*)

Additional Operators (name and date of birth)

List Prior Vessels Owned (Length and Kind of Vessel)

Years as a Boat Owner

Years of Marine Experience

Boater Safety Courses taken

Prior Losses?

VESSEL

Year (*)

Length (*)

Make (*)

Model (*)

Hull ID (*)

Hull Material FiberglassWoodOther

Engine Information

(*) SingleTwinTripleQuadOther

(*) GasDiesel

(*) InboardOutboardI/OSail

Engine Year

Manufacturer (*)

Model (*)

Horse Power (total) (*)

Serial Number(s)(*)

Survey Available?

Racing or Charter use

Max Speed

Summer Location

At DockMooring

Winter Mooring

In WaterOut of Water

Layup Period (12/1- 5/1 Standard)

SAFETY EQUIP: GPSRadarShip To ShoreDepthCO DetectorFire Suppression

NAVIGATION LIMITS
Other Navigation:
Maine to Morehead City, NC 7 Month NavigationInland Waters (Non-Salt) 7 Month NavigationAtlantic Coastal Waters 7 Month Navigation*Inland Waters (Non-Salt) 12 Month NavigationAtlantic Coastal Waters 12 Month Navigation* between Eastport ME to Pensacola, FL *From June 30th to November 1st navigation is restricted to Eastport, ME to Morehead City, NC

COVERAGE LIMITS

Boat and Motor Value $ (Survey Value, Purchase Price, BUC Value)

Amount Financed?

Tender?

Trailer?

Will applicant be living aboardNoYes

LEINHOLDER:

ADDITIONAL NOTES:

Liability quoted at $500,000 unless otherwise requested.