If you are human, leave this field blank.ReferralName of Referring Dealership or Company *Contact Person *Phone *Email *Boat & Yacht Insurance Quote FormFirst Name *Last Name *Primary Physical Residence *City *State *SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingZip Code *Mailing address (if different) *Date of Birth *Drivers License Number *Home Phone *Cell *Fax *Email *Marital Status *SelectDomestic PartnershipDivorcedMarriedSingleWidowedHome Ownership Status *SelectOwn Home/CondoRentGender *SelectMaleFemaleOtherYear Built *Length of Vessel *Manufacturer *Model *Hull ID *Requested Effective Date *Purchase date or financial loan closing datePurchase Price (in USD) *Include taxes; title and registration feesNumber of engine(s) *Select1234Maximum Speed (mph) *Horsepower each engine *Engine Type *SelectInboardInboard/OutboardOutboardPod/IPS/ZeusAir PropJetHull Material *SelectFiberglassInflatableAluminumWoodSteelOtherFuel Type *SelectGasDieselElectricHas the applicant previously owned other watercraft? *YesNoIf yes then fill in the following details.If multiple watercraft, list largest to smallest.Make(s) *Length(s) *Number of Years Owned *Has the applicant previously operated other watercraft? *Including family, friends and rental boats.If yes then fill in the following details.Make *Length *Number of Years Operating *Any boating claims/losses within last five years? *YesNoIf you had a loss please provide the following details.Date of Loss *Cause of Loss *Nature of Loss *Amount of Loss (USD) *Has the applicant or any operator had any vehicle driving violations in the past 5 years? *YesNo(ticket, accident, felony, DUI)If yes then tell us about the violation.Operator Name *Violation Description *Date of Violation *Additional Experience, Claims or Violations? *If the applicant has owned more than one boat or has had additional claims or driving violations in the past 5 years provide details.Mooring Address *If marina or storage facility, please include the name of the business.City *State/Territory *SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingZip/Postal Code *Requested Navigation Territory *SelectInlandAtlanticPacificGulfGreat LakesChesapeakeBahamasCaribbeanVessel Use *Private PleasureCharter (6 pack)Charter (Bare Boat)Live-aboardTypes of Storage: *Selectdock/sliphurricane proof rack storagelocked enclosureon a lifton a trailer insideon a trailer outsiderack storageLoss Payee *Loss Payee Address *Trailer Year *Trailer Make *Trailer Serial *Trailer Value *Engine #1 Year *Engine #1 Make *If Outboard, Engine #1 Serial *Engine #2 Make *Engine #2 Year *If Outboard, Engine #2 Serial *Hull Value (less trailer value) *P&I Liability *$100,000$300,000$500,000$1,000,000Trailer *Medical Payments *$5,000$10,000$25,000Uninsured Boater *$100,000$300,000$500,000$1,000,000Personal Effects *$1,000$2,500$5,000$10,000Towing Coverage *$500$750$1,000$1,500$2,500 *Any Relevant Files *Submit
