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Powerboat Insurance Quote Form

Contact Information

Name (required)
Address
Address 2nd line
City
State
Zip
Contact me by Phone E-Mail Fax
EMail (req'd)
Work Phone Best Time
Home Phone Best Time
Fax

Current Insurance Information

Current Insurance Company (Not Agency)
Date Current Policy Expires mm/dd/yyyy

Your Vessels

  Vessel 1 Vessel 2
Year
Length in Feet
Mfg
Model
Max Speed (mph)
Type of Craft


explain if "other"


explain if "other"
Hull Material
Name of Craft

General Information

Purchase Price $ $
Date of Purchase mm/dd/yyyy mm/dd/yyyy
Storage / Mooring Location
Standard Area of Usage (Where is the Vessel Primarily Operated?)
Vessel 1
 
Vessel 2
Anticipated Trips Outside Standard Usage Area
Vessel 1
 
Vessel 2
Live on Board Yes No Yes No
Lay-Up Period Beginning Month
Ending Month
Beginning Month
Ending Month
Commercial Use Yes No Yes No
Used for Towing Sports
(skiing etc.)
Yes No Yes No
Paid Crew Yes No Yes No

Equipment / Maintenance

Date of Last Survey mm/dd/yyyy mm/dd/yyyy
Drive
Engine(s)
Engine Make
Engine Year
C.I. / H.P. (per engine)
Fuel
Fixed Fire System Yes No Yes No
Fume Sniffer Yes No Yes No

Requested Coverage Limits

Hull Value
(Insuring Amount)
Motor Value
(Insuring Amount)
Trailer Value
Tender / Dinghy Value
Accessory Value
Physical Damage Deductible
Liability Limit (applies to all vessels on policy)

Owner Information

Prior Boats Owned
Occupation of Owners
If Multi-Party Ownership, list names of other Owners including Companies.

Coverage Information

Current Insurer
Expiration Date of Current Policy mm/dd/yyyy
Requested Effective Date mm/dd/yyyy

Operators

Operator Operator Name Date of Birth
(mm/dd/yyyy)
1
2
3
4
Operator Driver License Number Years
Licensed
Years
Boating
Experience
Courses
1
If Other
2
If Other

Driving Violations (not boating violations)

Incident Driver Involved Ticket / Violation
Violation Date
(mm/dd/yyyy)
1
2
3
4

Questions, Comments or Concerns

This is a Request For Quotation Only.
No coverage is in effect until bound by an insurance carrier.

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Thank You!