HIGILOGO.GIF (1070 bytes)Personal Pleasure Boat Quote RequestHOUSE.GIF (3661 bytes)

 

 

Name:
Mailing Address: 
City:    State:    Zip: 
Phone:      Fax: 
E-mail Address (If Any):  
DOB 
Social Sec #:

Description Of Property - Insured Watercraft

Motor Type:    Outboard   Inboard   Outdrive   Twin Engines   No Engine

Fuel Type:    Diesel    Gas   Max Speed:

Boat Type:   Power    Sail (With Or Without Aux. Motor)   Other   

Boat Year Manufacturer Model Length Total H.P.
Outboard Motors
Trailer
Purchase Price
 Purchase Date

            

Coverages

Amount Of Insurance

 Deductible
Boat 5-10%
Outboard Motor 1.
Outboard Motor 2.
Boat Trailer $100.00
Personal Property
Commercial Towing No Deductible
Boat Liability
Medical Payments
Uninsured Boater
Optional Coverages Fishing Equipment
Agreed Value - I/O

 

Safety Equipment:

Vapor Detector    Automatic CO2 (Halon)   Depth Sounder

Radar Loarn    Ship/Shore Radio (VHF)   Electronic Burglar Alarm

Waters To Be Navigated:

Inland Non-Tidal Waters Of The Following States:  

Coastal Waters Of The Following States:  

Chesapeake Bay   Great Lakes   Puget Sound   San Francisco Bay  Other:

Mooring Location & Lay-Up:

Location During Navigation Season:

Residence    Marina      Name & Location of Marina:   

Lay-Up Period: (Month/Day)

From:     To:       Hauled   Afloat    Bubbler System:   Yes   No

Location During Lay-Up Period:

Residence    Marina       Name & Location of Marina:  

Owner/Operator Information:

Operator's Name Birth Date Years Exp. % Use Drivers License # & State Motor Vehicle  Accidents/Convictions

Have You(Or The Principal Operator Listed Above) Completed Any Boat Safety Course Offered
By The Following Organizations?  (Check If Applicable)

US Power Squadron    US Coast Guard   Other:  

Previous Boats Owned/Operated (Specify Type/Size/Years Owned)


Previous/Current Insurance Company:  

Boating Losses:   Date:     Operator Name:    Amount:  

Description Of Lossses:  

Has Insurance Ever Been Cancelled Or Declined:    Yes    No

If Yes Give The Reason:  

Do You Use Ypour Boat For Water Skiing?   No   Yes    What Percentage Of Time: 

Is The Boat Chartered Or Used For Other Than Private Pleasure Purposes?  Yes    No

If Yes, Explain In Remarks:  

Any Remarks Or Comments?  Please Place Them In The Form Below

  

 

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