Marine Marine Insurance Services Ownership Information Name* First Last Date of Birth Date Format: MM slash DD slash YYYY Phone*Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Corporately Titled?SelectNoYesEmail Address (Required)* Preferred Method of ContactSelectPhoneEmailResidence StatusSelectOwnRentMarital Status (Discounts May Apply)SelectMarriedSingleDivorcedWido / WidowerOccupationAgent You are Working With?SelectAny Is FineAdam MeyerGarrison RudisillRod ClingmanNick McGintyDavid MorrowCarly HetzelVance BarkerNed SawyerMike GlaesnerHow did you hear about us?SelectInternet SearchReferral from current clientBoat Show or Similar EventYacht Broker / Yacht DealerOtherBoating History & ExperienceHow Many Years of Boating Experience Do You Have?Have You Owned Boats Before?SelectYesNoHow Many?Select0123+Total Years of Vessel Ownership:Any Boating Claims?SelectNoYesBoating Courses?SelectNoYesHas Your Insurance Ever been Cancelled or Non-Renewed?YesNoHave you had any Felony Convictions?YesNoHave you had any automobile or boating violations in the past 3 years?YesNoHave you filed for Bankruptcy?YesNoVessel Information Model YearVessel LengthBuilder / Manufacturer:ModelPurchase PricePurchase Date Date Format: MM slash DD slash YYYY Hull MaterialSelectFiberglassAluminumWoodSteelOtherHull TypeSelectRunaboutCenter ConsoleCruiserPontoon / TriToonMono Hull SailboatMulti Hull SailboatHouseboatBass BoatInflatableOtherFuel TypeSelectGasolineDieselElectricEngine TypeSelectOutboardPodsInboardInboard/Outboard DriveNumber of EnginesSelect1234Engine Mfg.Engine YearHorsepower Per EngineTop Speed (MPH)Additional Equipment - Please Check All That Are Onboard The Vessel GPS Radar Depthfinder EPIRB CO Detector Offshore Life Raft Survial Suits Auto Fire Extinguisher Vessel Monitoring System Do you want Trailer Coverage?YesNoWas the Vessel purchased as salvage or have any existing or prior damage?YesNoIs the vessel financed?YesNoHas the Vessel or Engine(s) been modified or altered from stock condition?YesNoDo you have insurance on this vessel currently?SelectYesNoWho is the Current Insurance Company?Mooring Location and Vessel Navigation and UsageSummer Mooring Location, (City / State or Country)Summer Location TypeSelectDockMooring BuoyTraileredStationary Boat LiftInside RackOutside RackStandsMarina / Facility NameIs the winter mooring Different from Summer?SelectNoYesVessel UseSelectPleasurePassenger CharterCommercialIs the vessel kept more than 400 miles from owners residence?YesNoWill The Vessel Be Used For Racing?YesNoIs the vessel currently held for sale?YesNoDo you employ a paid Captain or Crew?YesNoPrimary NavigationSelectUS Atlantic Southeast Coast - (VA / NC / SC / GA)US New England (ME - VA)US East Coast & Bahamas - Warranted North of FL from 06/01-11/01US East Coast & BahamasUS East Coast & Bahamas - Warranted North of Cape Hatteras from 06/01-11/15US East Coast North of FL - Year RoundUS East Coast - North of Morehead City - Year RoundChsapeake Bay OnlyGulf Coastal WatersInland Lakes & Rivers - Excluding Great LakesInland Lakes & Rivers - Including Great LakesUS West CoastOtherDo you require secondary navigation?SelectNoYesDoes Your Vessel Lay-up Out of Commission?YesNoAdditional Navigation / Mooring / Storage Notes:Coverage SectionInsured Vessel Value RequestedHull Deductible (% of Insured Value)Select1%2%3%4%5%Liability LimitSelect$300,000$500,000$1,000,000$2,000,000More than $2,000,000Uninsured BoaterSelect$300,000$500,000$1,000,000Medical PaymentsSelect$1,000$2,500$5,000$10,000$15,000$25,000$30,000Personal EffectsSelect$1,000$2,500$5,000$10,000$15,000$25,000Trailer Coverage LimitDate Coverage is Needed Date Format: MM slash DD slash YYYY Boat SurveyComments or Questions for Agent?
