Boat Insurance Quote Form

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

MonthDayYear
Source of Business (Applicant / Brokered)
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number

Area CodePhone Number
E-mail Address
Marital Status

MarriedSingleSeparatedDivorcedDomestic PartnershipWidowed
Owner's Residence Status

OwnRentOther
Multiple Unrelated Owners?

YesNo
Losses in Last 5 Years?

YesNo
If Yes to Losses in Last 5 Years, Provide Date & Description:
Operator Information
Primary Operator Name

First NameLast Name
Date of Birth
Date of Birth

MonthDayYear
How many years have you owned boats?*
Prior Owned Boats
MVR Violations(Required if vessel max speed is > 65mph)
Occupation
Boating Courses

YesNo
Age of Youngest Operator
Vessel Information

Vessel Length and Max Speed

Rows	Enter Amt.
Vessel Length (feet):
Max Speed (mph):

Hull Type

Single HullMulti-Hull
Vessel Type

PowerSail with EngineSail no EngineHouseboatPontoonNon-powered small craft (includes rowing shell, drift boat, kayak)
Charter or Commercial Use?

YesNo
If Yes, Describe:(Include Charter type and number of days of charter annually)

Lay-Up Period (vessels > 26 ft.):

Rows	(mm/dd)
From:
Until:

Safety Equipment

Built-In Fire Extinguishing System
Year Built
Manufacturer
Model
Hull Material
Purchase Price
Purchase Date
Purchase Date

MonthDayYear
Storage / Mooring

Street Address

Street Address Line 2

CityState

Zip Code
Navigation Area:
Engine Information
Engine Type

OutboardInboardInboard / Outdrive
Fuel Type

Gas No Fume DetectorGas Fume DetectorDiesel
# of Engines
Manufacturer
Year Built
Rows 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 StaffInsuredOther
Agency Staff
Should be Empty: