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English (US)
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Request of an Insurance Quote
Please fill the form accurately for better assistance
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Enter a valid Phone Number
*
Format: (000) 000-0000.
FullOccupation
*
Nationality
*
Please Select
White
African American
Hispanic or Latino
Asian
Native Hawaiian
American Indian
Alaska Native
Date of Birth
*
-
Month
-
Day
Year
Date
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Boating Experience (in years) and any boating qualifications and previous vessels owned or operated?
*
Any Marine claims or losses in the last five years?
*
Yes
No
How long have you had no claims bonus from a recent marine craft policy
*
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Convicted of or charged (but not yet tried) with a criminal offence?
*
Yes
No
Been declared bankrupt/insolvent, or County Court Judgment?
*
Yes
No
Insurer declined claims/cover or special terms imposed?
*
Yes
No
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Use
*
Vessel Name
Year of Purchase
*
Purchase price (and any finance secured on the vessel)?
*
Kind of construction
*
Manufacture
*
Model
*
Year of construction
*
Material construction hull
*
Material construction mast
Total value to be insured $
*
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Sail area in square meters
Limit speed
*
Length
*
Width
*
Flag/Country of Registration
*
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Yacht in class (for example RINA) or current survey available?
Hull and machinery value?
Tender value?
Outboard value?
Any other items and values connected to the vessel?
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Do you require waterskiing or towing of water toys cover?
*
Yes
No
Does the vessel require road transit cover?
*
Yes
No
When will you be requiring cover to start?
*
-
Month
-
Day
Year
Date
Age of rigging:
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Inboard or outboard engine
*
inboard
outboard
Jet ski
Power of the engine (in hp/kw please advise)
Manufacturer/Type
Year of construction
Type of Drive
*
Please Select
Jet Engine
Shaft drive
IPS drive
surface drive
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Mooring City/Location
*
Cruise Area / Navigation Limit
*
Puerto Rico and Caribbean Sea within the scope of Clause 1015 (including cover for named storms)
Which type of insurance are you looking for?
*
All Risk Insurance
I understand
*
Any person who knowingly and with the intent to defraud presents false information in an insurance request form, or who presents, helps, or has presented a fraudulent claim for the payment of a loss or other benefit, or presents more than one claim for the same damage or loss, will incur a felony, and upon conviction will be penalized for each violation with a fine of no less than five thousand dollars ($5,000) nor more than ten thousand dollars ($10,000); or imprisonment for a fixed term of three (3) years, or both penalties. If aggravated circumstance prevails, the fixed established imprisonment may be increased to a maximum of five (5) years; if attenuating circumstances prevail, it may be reduced to a minimum of two (2) years. Any person who, knowingly and with intent to defraud the insurance company or other person, files an application for insurance containing any false information or conceals for misleading, information containing any fact material thereto, commits a fraudulent insurance act violation, which is a crime.
Please verify that you are human
*
Submit
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