PERSONAL BOAT QUOTE       

OWNER INFORMATION  

        Yacht Owner                                         
        Date of Birth                                         
        Address                                                 
        City                                                         
        Zip Code                                                
        Phone Number                                     
        Fax Number                                          
        E-Mail Address                                     
        Who Referred You to Our Site?           

        Years Yacht Operator Experience    
        Years Yacht Ownership Experience 

        Previous Yachts Operated (year, length, make)                   

        Previous Yachts Owned (year, length, make)                      

- Private Pleasure Charter Live Aboard Racing Professionally Crewed Scuba/Water Skiing                                   Use of Yacht

- U.S.P.S U.S.C.G Captains License Other                                           Educational Courses Completed    Other: 

- Yes No                                                               Losses in Past (5) Years

                                                     If Yes, Date

                                If Yes, Amount Paid Out  

        If Yes, Description                                            

VESSEL INFORMATION

        Year                                                        
        Make                                                       
        Model                                                     
        Length                                                   

        Hull Construction                                

        Number of Engines                                   

- Gas Diesel Other                                                           Fuel Type     

        Horsepower Each Engine 

- Yes No                                                               Automatic Halon or CO2                       

- Inboard Outboard Inboard/Outboard Jet-drive                                           Engine Type     

        Top Speed  

        Purchase Price                                          

        Purchase Date 

- GPS Loran VHF Radar Depth Sounder EPIRB Fume Detector Burglar Alarm                                               Electronic Aids

        Date of Last Survey      Dry   Afloat

COVERAGE INFORMATION

        Hull Coverage                                         

- 1% 2% 3% 4%                                                                Deductible                                     

- $300,000 $500,000 $1,000,000                                                     P & I Liability                                           

- $1,000 $5,000 $10,000 $25,000 $50,000                                                         Medical Payments                                  

- $1,000 $2,500 $5,000 $10,000 $25,000                                                         Personal Property                                  

- $300,000 $500,000 $1,000,000                                                     Uninsured Boaters (should match liability amount)

- $500 $1,000 $5,000                                                           Towing & Commercial Assistance      

Trailer:                                                  

        Value                

        Year                   

        Make                  

- 1 2 3 4                                                                   Axel                                           

Tender:

        Value

        Year

        Make

        Model

        Length

        Horsepower

ADDITIONAL INFORMATION

        Navigational Territory 

        Mooring Location         

- None 6 Pac 12 Pac                                                           Number of Charters     

        Fishing Tackle Value              

ADDITIONAL COVERAGES/OPTIONS

Additional Operators:  

        Name 

        Date of Birth  

        Years Experience 

- None Yes No                                                             Additional Insured       

- None Yes No                                                             Loss Payee      

- Yes No                                                               Coverage ever cancelled                                            

MISCELLANEOUS INFORMATION

        Current Insurance Company   
        Expiration Date                           
        Current Premium                        

Questions or Comments to help the Agent:

               

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