Boat/Yacht Quote Request Form

Boat/Yacht Quote Request Form

I know, it's a little long but please be as accurate as possible
Applicant Info
Named Insured(s)

First NameMiddle NameLast Name
Does named insured match vessel title?
Owner Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Is Corporation sole purpose for holding vessel?
Occupation
Mailing Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Primary Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Vessel Details
Vessel Year
Vessel Length
Manufacturer
Model
Hull ID
Vessel Name
Date Purchased

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Purchase Price
Hull Material
Vessel Type
Vessel Use
Charter Details if needed
Survey Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Surveyor Name
Survey Type
Survey Value
Engine & Performance
Number of Engines
Engines Year
Engines Horsepower
Engines Manufacturer
Engine Model
Engine Type
Engine Fuel Type
Max Speed (mph)
Tender/Trailer Details
Tender Year
Tender Length
Tender Manufacturer
Tender Model
Tender Estimated Value
Tender Engine Details
Navigation & Storage
Requested Navigation Area
Miles Offshore
Berthing/Storage Location Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Storage Type
Layup Type
Layup Dates

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Effective Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Operator & Crew
Primary Operator Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Marital Status
Spouse Also Operates Vessel
Years of Boating Experience
Years of Vessel Ownership
Boating Training Completed

Other
Prior Vessels Operated
Additional Operators & Crew Present

Other
Additional Operators & Crew Details
Additional Operators & Crew Schedule, Count, and Duties
Coverage
Coverage A - Hull Limit
Coverage A - Deductible
Coverage B - Liability
Coverage C - Medical Payments
Coverage F - Personal Property
Additional Insured Name

First NameMiddle NameLast Name
Additional Insured Type
Current Insurance & History
Current Insurance Carrier
Annual Premium
Any Losses or Claims?
Loss Details
Policy Declined or Canceled?
History Details
Vessel Condition & Exposures
Describe damage or repairs
Modifications made to the vessel

Other
Is the vessel used for racing or high-speed events?
Lithium battery installed on board

Other
GPS or chartplotter installed

Other
Fire suppression and safety equipment on board

Other
Insured Signature
Printed Name

First NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Boat/Yacht Quote Request Form

Applicant Info

Vessel Details

Engine & Performance

Tender/Trailer Details

Navigation & Storage

Operator & Crew

Coverage

Current Insurance & History

Vessel Condition & Exposures