subject_line
Broker Information
Agency Name
Broker Name:
Broker Email:
Broker Phone:
Date Quote is Needed:
Agent You are working with:
Any is Fine
Nick McGinty
Vance Barker
Kerry Condes
Garrison Rudisill
Insured Information
INSURED NAME:
If Corporation: Beneficial Owner's Name
Street Address:
City, State Zip Code
DATE OF BIRTH
ANY CLAIMS FOR INSURED?
NO
YES
Check any that Apply
DUI
Bankruptcy
Felony
Insurance Cancelled
Residence:
Own
Rent
Married
Yes
No
IF CLAIMS: YEAR / AMOUNT / DETAIL:
NUMBER OF YEARS - OWNING A VESSEL:
NUMBER OF YEARS BOATING:
# Of Vessels Owned
1
2
3
4+
Courses / Licenses:
Sailing School
ASA
Captains License
USCG
Power Squadron
Other
Captain's Level:
6 Pack
25 Ton Masters
50 Ton Masters
100 Ton Masters
+ 100 Ton Masters
Describe Other
1st PRIOR VESSEL OWNED: MAKE, LENGTH, # OF YEARS
2ND PRIOR VESSEL OWNED: MAKE, LENGTH, # OF YEARS
3RD PRIOR VESSEL OWNED: MAKE, LENGTH, # OF YEARS
VESSEL INFORMATION
YEAR PURCHASED:
PURCHASE PRICE:
VESSEL NAME:
YEAR:
MAKE:
LENGTH:
ENGINE MAN.:
# ENGINES
1
2
3
4
HP (EA):
PRIMARY MARINA / STORAGE LOCATION:
USE
PRIVATE PLEASURE
COMMERCIAL - NON CHARTERING
CHARTERS - UNDER 10 YEAR
CHARTERS - 10-21 / YEAR
OVER 21 CHARTERS / YEAR
PAPER CHARTER ONLY (PERSONAL / CORPORATE)
TYPES OF CHARTERS
FISHING
SIGHTSEEING
EXCURSION
OTHER
Describe Commercial Use:
CRUISING AREA
PRIMARY NAVIGATION:
INLAND WATERS, INCLUDING GREAT LAKES
INLAND WATERS - EXCLUDING GREAT LAKES
US EAST COAST - NORTH OF FLA YR ROUND
US EAST COAST, FLA, GULF & BAHAMAS - NORTH OF FLA 7/1-11/1
US EAST COAST, FLA, GULF & BAHAMAS - NORTH OF CAPE HATTERAS 7/1-11/1
US EAST COAST, FLA, GULF & BAHAMAS - NO RESTRICTION
GULF OF MEXICO
WEST COAST US & MEXICO
-
Do you need additional Navigation?
Yes
No
SECONDARY NAVIGATION (CHECK ALL THAT APPLY):
BERMUDA
CARIBBEAN
CENTRAL AMERICA
VENEZUELA
COLUMBIA
Does The Vessel Lay-up:
Yes
No
Lay Up Dates
Lay-up Location
On Land
In Water
OTHER NAVIGATION:
General Information
Do you Employ Paid Crew?
Yes
No
Do you have a Tender:
Yes
No
Do you have a Trailer:
Yes
No
SURVEY AVAILABLE?
YES
NO
LIVE-ABOARD?
YES
NO
Survey Information:
SURVEY YEAR
In Water or Out Of Water:
Crew
FULL-TIME CAPTAIN:
YES
NO
YES TO CAPT - # YEARS ON THE VESSEL:
1
2
3
4
5
+5
FULL-TIME CREW (INCL CAPT)?:
NONE
1
2
3
4
5
PART-TIME CREW:
NONE
1
2
3
4
5
Tender / Trailer
TENDER: MAKE / LENGTH / VALUE:
DO YOU TOW YOUR TENDER?:
YES
NO
N/A
Trailer: Year / Make / Value
COVERAGE NEEDED
INSURED VALUE:
DEDUCTIBLE:
1%
2%
3%
4%
5%
LIABILITY LIMIT:
$300,000
$500,000
$1,000,000
$2,000,000
$3,000,000
$4,000,000
$5,000,000
OVER $5MM
PERSONAL PROPERTY:
$5,000
$10,000
$20,000
$30,000
$50,000
FISHING GEAR:
$10,000
$20,000
$30,000
$50,000
$100,000
MEDICAL PAYMENTS:
$10,000
$20,000
$25,000
$50,000
TENDER VALUE:
Additional Information:
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