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Quote for Yacht Insurance

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. 
Named Insured (Vessel Owner):   Date of Birth:
Address:
City:
State: Zip: 
Occupation:
Mortgage: Yes No

Owner and Operators
Years as Owner (All Boats)?
Years as Operator/Crew?
Size of Last Yacht Owned?
Formal Boating Education:
Number of Paid Capt./Crew

Vessel And Equipment
Purchase Price:  New Vessel Replacement Cost:
Manufacturer: Year:
Length: Model:
Type: Power Sail Max Speed:
Vessel Name:
Construction:

Fiberglass

Wood

Steel/Alum

Other
No. Engs:  HP Each: Manufacturer: Fuel: Engine Type:
Gas Diesel
Automatic Built-In Fire Extinguishing System: Yes No
Dinghy: Length: Make/Model: Value:

Operation Of Vessel
NAVIGATION LIMITS REQUIRED
Check all that apply
US East Coast Maine to Florida US East Coast Maine to Texas
US East Coast Maine to North Carolina Including Bahamas
Mexico Caribbean
Pacific Mediterranean
Worldwide Other:
Yacht Will Be Laid Up And Out Of Commission Annually: From: To:
Principal Mooring Location: (Include Location, Address, State, County, and Zip  Code)

Previous Carrier
Has any Insurance Company canceled, or refused to renew?  Yes No
(If Yes, Explain)

Prior Losses
List all claims (Explain in detail, i.e. Cause, Amount Paid, Etc. If No Losses, state “None”)

Insurance Limits Requested
Effective For One Year Beginning: 
Hull & Machinery: Deductible Options:
Protection and Indemnity (Liability):
Medical Payments:
Uninsured Boater:
Yacht Trailer:
Personal Property: Other Amount:
Other:
How would you like to be Contacted?
E-Mail:  Phone: 
Fax:  US Mail:

Consumer  Information

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. 

I have read the above quote request and declare that to the best of my knowledge all the foregoing statements are true. I understand that any concealment of any material fact could affect this insurance coverage. I further understand  and agree that this insurance is subject to final underwriting approval by the Company. Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing false, incomplete or misleading information is guilty of a felony of the third degree.