Boat Insurance : Request for Information
1-888-822-2400
Be safe on the seas! Be sure to insure your boat!
• Loss or damage to any property
• Bodily injury or loss of life
• Removal or failure to remove the wreck of your boat
General Information
Name:
Address:
City, State & Zip:
Phone Day/Eve:
Email:
Boat Information
Name of Boat
Year
Model
Manufacturer
Registration No.
Length
Adv. Max. Speed
Date Purchased
Purchase Price
Present Value
Type of Boat
Hull Material
Fuel Tank Material
Engine Manufacturer
Horsepower
Fuel
Berth / Mooring Location
Trailer (if any)
Year
Manufacturer
Model
Serial Number
Capacity
Purchase Price
Waters navigated:
Lay-up from
To
Location
Equipment
#
Type
Check those that apply
1
Bilge Pumps
2
Cooking Stove
3
Fume Detector
4
CO2/Halon System
5
Fire Extinguishers
6
Depth Sounder
7
Radar
8
Radio Direction Finder
9
Ship to Shore Radio
10
Anti-Theft Devices
11
Automatic Fire Extinguisher
12
Other:
Operator
#
Name
Date of Birth
Auto Drivers License #
State
Years Boating Experience
1
2
3
4
General Information
#
Explain all "YES" responses in the remarks section below
Yes
No
1
Is the boat chartered to others?
2
Is the boat used commercially or for business purposes?
3
Is the boat used for racing?
4
Is the boat used for water skiing?
5
Does the applicant employ a paid crew?
6
Was any drivers license suspended or revoked within the last 5 years?
7
Did any loss occur during the last 5 years?
8
Was any coverage declined, cancelled or non-renewed during the last 5 years?
Please enter any remarks and/or questions here:
Where may the boat be inspected?
Address
Name of Person to contact:
Phone Number:
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