Page Insurance, Ltd
102 Boston Street
Guilford, CT 06437
(203) 453-5258
info@pageins.com
Applicant / Customer Information
Requested Date of Coverage
Requested Date of Coverage
-
Month
-
Day
Year
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Source of Business (Applicant / Brokered)
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
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District of Columbia
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Tennessee
Texas
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State
Zip Code
Phone Number
-
Area Code
Phone Number
E-mail Address
Marital Status
Married
Single
Separated
Divorced
Domestic Partnership
Widowed
Owner's Residence Status
Own
Rent
Other
Multiple Unrelated Owners?
Yes
No
Losses in Last 5 Years?
Yes
No
If Yes to Losses in Last 5 Years, Provide Date & Description:
Operator Information
Primary Operator Name
First Name
Last Name
Date of Birth
Date of Birth
-
Month
-
Day
Year
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How many years have you owned boats?
*
Prior Owned Boats
MVR Violations
(Required if vessel max speed is > 65mph)
Occupation
Boating Courses
Yes
No
Age of Youngest Operator
Vessel Information
Vessel Length and Max Speed
Enter Amt.
Vessel Length (feet):
Max Speed (mph):
Hull Type
Single Hull
Multi-Hull
Vessel Type
Power
Sail with Engine
Sail no Engine
Houseboat
Pontoon
Non-powered small craft (includes rowing shell, drift boat, kayak)
Charter or Commercial Use?
Yes
No
If Yes, Describe:
(Include Charter type and number of days of charter annually)
Lay-Up Period (vessels > 26 ft.):
(mm/dd)
From:
Until:
Safety Equipment
Built-In Fire Extinguishing System
Year Built
Manufacturer
Model
Hull Material
Purchase Price
Purchase Date
Purchase Date
-
Month
-
Day
Year
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Storage / Mooring
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Navigation Area:
Engine Information
Engine Type
Outboard
Inboard
Inboard / Outdrive
Fuel Type
Gas No Fume Detector
Gas Fume Detector
Diesel
# of Engines
Manufacturer
Year Built
Each
Engine Horsepower:
Insuring Amounts
Current Insurance Co.
Current Premium
Vessel & Engine(s)
Deductible
$250
$500
$1000
Liability
Optional Coverages
Trailer
Tender
Submitted by
*
Agency Staff
Insured
Other
Agency Staff
Please Select
Astrid Page
George Page
Submit
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