Personal Boat Insurance

An Online Watercraft Insurance Quote Form

APPLICANT INFORMATION:

Request Date:

Applicants Name:

Street Address:

City:

County:

State:

Zip Code:

Home Phone:

Work Phone:

Fax Number:

E-mail Address:

Vessel Currently Insured?

yes no

If Insured - Name of Company:

Previous Boats Owned (Size & Length)

Applicants Experience in Years

Boat Type:

Sail Power

Use of Boat:

Day Trips Cruising Racing Other

Where is vessel stored?

Waters Navigated?

Inland Lakes and Rivers Atlantic Coastal Great Lakes Chesapeake Bay Long Island Sound Pacific Coastal Gulf Coastal

Any Water-skiing?

yes no

LIST ALL OPERATORS:

Full Name:

Age

Training

Tickets

Description

yes no

yes no

yes no

yes no

yes no

yes no

yes no

yes no

HULL:

Manufacturer:

Make:

Model:

Year Built:

Hull Type:

Fiberglass Wood Aluminum Other

Length:

Total Horsepower:

Maximum Speed:

Estimated Market Value:

ENGINE(s)

Inboard Outboard I/O None Sail

#

YEAR

MANUFACTURER

HP

FUEL

1

Gas Diesel None (Sail)

2

Gas Diesel None (Sail)

3

Gas Diesel None (Sail)

4

Gas Diesel None (Sail)

TRAILER:

yes no

Manufacturer:

Make:

Model:

Year Built:

Trailer Value:

TENDER/DINGHY:

yes no

Manufacturer:

Make:

Model:

Year Built:

Length:

Engine Make:

Horsepower:

Current Market Value:

COVERAGE REQUEST:

Hull and Equipment Limit:

Deductible Amount:

$250 $500 1% 2% 5%

Misc Boating Equipment Limit:

Personal Effects Limit:

Dinghy/Tender & Motor Limit:

P & I Liability Limit:

100,000 250,000 500,000 1,000,000

Medical Payments to Others Limit:

1,000 5,000 10,000 None

Trailer Limit

Waterway Services Limit:

EXPLAIN ALL YES ANSWERS BELOW:

Has any listed operator been involved in a boating accident within the past 5 years?

  yes no

Has your boat and / or equipment suffered damage from any cause within the past 5 years ?

  yes no

Has any listed operator been involved in an auto accident in the past 3 years?

  yes no

REMARKS