HULL INSURANCE QUOTE REQUEST

Name of boat/vessel owner *

Contact name if different from above

First Name Last Name

Mailing address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Is mooring/docking or storage location same as mailing address *

Yes No

Enter mooring/docking or storage location *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone number *

Area Code Phone Number

E-mail *

Confirmation Email

Describe security measures at storage/mooring location *

Boat details: *

	Cost to Replace	Make/Model	Serial or ID #	Date Purchased	Year Built	Material	Length
1
2
3
4
5
6

Any other boats?

Add more

Boat Details:

	Cost to Replace	Make/Model	Serial or ID #	Date Purchased	Year Built	Material	Length
1
2
3
4
5
6
7
8

This coverage includes $2500 personal property - (paddles, PFDs, other equipment used to paddle - subject to deductible) - If you would like additional limits choose from below

5000 10000 25000

Name of 3 responsible users: *

	FULL NAME	AGE	YEARS EXPERIENCE	RELATIONSHIP TO BOAT OWNER (OWNER, CLUB PRES, COACH, ETC)
1
2
3

Do you have a trailer to add? *

Yes please add trailer No trailer

Trailer *

	YEAR	MAKE/MODEL	SERIAL OR VIN#	STORAGE LOCATION	REPLACEMENT VALUE
1
2

Waters where vessel/s will be used primarily: *

Do you currently have insurance coverage? *

No Yes

Name of current insurance carrier?

Have any paid loss' occurred within the past 3 years?

No Yes

Describe Loss type, amount paid, date loss occurred.

Expiration date of current insurance carrier?

Notes/comments:

Add any additional information; suggestions or feedback

I warrant that the information provided is true to the best of my knowledge and understand that quotes will be based on information provided.

Clear

Name of named insured or authorized board member

First Name Last Name

Date

Date Date Picker Icon

A copy of this form will be emailed to the address entered or you may print a copy for your records. Depending on the location, type of boats quotes can take between 4 hours to 48 hours. Please indicate in the comments box if you need coverage immediately.

HULL INSURANCE QUOTATION REQUEST