AT THIS TIME WE CAN ONLY QUOTE THIS COVERAGE FOR TEXAS RESIDENTS.
PLEASE FILL OUT COMPLETELY.
First and Last Name Phone Number Fax Number Email Address Work Number Is this for: Ind/Family Partnership Corporation Marina Name Zip Code of Marina Previous/Current Policy Number Current Ins. Co. None Make & Model Year Length HP Hull ID Stated Value Trailer Value Year Boat was Purchased Purchased New Pre-Owned Is the craft financed No Yes Previous Boats Owned Will this boat be navigated year round No Yes If no, laid up form what month to what month; from Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec to Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec Laid up On Shore Afloat On Lift PREMIUM DISCOUNT FOR A LAY-UP PERIOD Used in Fresh Water Salt Water Both Overnight Storage Lift Driveway Parking lot Garage Yard Street Prior Losses None Theft Submerged Object Injury Engine Collision Other If any losses: Yr. of Loss $ Paid Yr. of Loss $ Paid Liability Limit Requested $25,000 $50,000 $100,000 $300,000 $500,000 $1,000,000 None Other Deductible Requested $500 $1,000 $2,500 Liability Only No Yes All Programs Include*: Uninsured Boaters Liability; Medical Payments; Towing/Roadside Assistance; Agreed Value; No Installments; Minimum Annual Premium is $175; A Minimum Earned Premium.
Who will be operating this craft? Boating Experience Name/Age Occupation #Tkts #Acc Years Boating Courses 0 1 2 3 4 5+ 0 1 2 3 4 5+ 0 1 2 3 4 5 6 7 8 9 10+ 0 1 2 3 4 5+ 0 1 2 3 4 5+ 0 1 2 3 4 5 6 7 8 9 10+ 0 1 2 3 4 5+ 0 1 2 3 4 5+ 0 1 2 3 4 5 6 7 8 9 10+ 0 1 2 3 4 5+ 0 1 2 3 4 5+ 0 1 2 3 4 5 6 7 8 9 10+ 0 1 2 3 4 5+ 0 1 2 3 4 5+ 0 1 2 3 4 5 6 7 8 9 10+
Have any of the above persons received a DUI No Yes If so, who and when
ADDITIONAL INFORMATION FOR BOATS OVER 26' Name of Boat Year Surveyed Number of Crew (If any) Chartered No Yes If chartered, how many times per year Dinghy Value Dinghy Year/Make Waters Navigated
How would you like us to contact you Email Phone Fax
Comments:
