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Marine Repair Liability Quote Request Form

Please note that completion of the following request for information does not constitute the purchase of insurance. No coverage may be added, changed or bound as a result of submitting this request for information or quotation of insurance. All coverage must be confirmed by the agency in writing subject to an acceptable signed application meeting the underwriting guidelines of the Insurance Company.
Name of Applicant:
Address:
City:
State: Zip:
Type of Work Performed (check all that apply):
Canvas Repair Canvas Installation
Carpentry Cleaning/Detailing
Electronics Repair/Installation
Fiberglass Gas Freeing
Painting Rigging
Welding
Engine repair/installation 
Brief Overview of Work Performed:
Type of Vessel Worked on? Private Pleasure Craft
Commercial Watercraft
If Commercial Watercraft, describe Percentage and type:
Are propellers pulled and/or replaced:
Maximum value any one vessel?
Maximum value of all vessels under repair at any one time?
Do you tow any watercraft? Yes No Do you haul/launch watercraft? Yes No
Do you operate any watercraft as part of your work? Yes No
If yes, describe:
Do you have the watercraft or any of its equipment in or on any property you own, rent or lease? Yes No
If so, please describe:
Do you have docks or slips at your place of business? Yes No
If so, how many?
Do any of your customers visit your place of business? Yes No
If yes, explain:
Are you a sub-contractor? Yes No Do you sub-contract work out? Yes No
If yes, explain:
How many years have you performed this work?
Gross receipts, including parts and labor: $
How many people do you employ?
Do you perform any other work/service, Or provide/sell any other parts, equip. or material in your business? Yes No
If yes, please explain and give amount of receipts of sales for this other operation:
Describe all losses, whether insured or uninsured, for the past (5) years:
Current insurance carrier:
Has your insurance ever been canceled? Yes No
If yes, explain:
Limit of Liability?
Include Protection of Indemnity Insurance? Yes No
Date policy is to be effective:
How would you like to be Contacted?
E-Mail:  Phone: 
Fax:  US Mail:
Please note that completion of the following request for information does not constitute the purchase of insurance.  No coverage may be added, changed or bound as a result of submitting this request for information or quotation of insurance.  All coverage must be confirmed by the agency in writing subject to an acceptable signed application meeting the underwriting guidelines of the Insurance Company. 
Applicant Name Date