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Sailboat 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 (feet)
Manufacturer
Model
Type of Craft
Other

Other
Hull Material
Name of Craft

General Information

Purchase Price $ $
Date of Purchase mm/dd/yyyy mm/dd/yyyy
Storage or
Mooring Location
Anticipated Trips
Outside Standard
Usage Area
Live on Board Yes No Yes No
Lay-Up Period 1st Month
Last Month
1st Month
Last Month
Commercial Use 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 )
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

Current CoverageInsurance

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
Oper Driver
License
Number
Years Licensed Years
Boating Exp
Courses
1
Other
2

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!