Boats, Yachts or Personal Watercraft Quote
CONTACT INFO:
NAME:
HOME ADDRESS: PHONE NUMBER: TYPE: ALT PHONE: TYPE: EMAIL:
HOME ADDRESS: PHONE NUMBER: TYPE: ALT PHONE: TYPE: EMAIL:DRIVER DATE LICENSE
DATE LICENSE NAME: OF BIRTH: & STATE RELATIONSHIP
OF BIRTH: & STATE RELATIONSHIPDRIVER INFO:
If there are additional drivers, please list their information here:
Have you moved in the past 3 years? if so, what was your last permanent address:
BOAT INFO
YEARMAKEMODELBOAT ID # (VIN) : BOAT VALUE MOTOR VALUE:ORIGINAL COST NEW
MAKEMODELBOAT ID # (VIN) : BOAT VALUE MOTOR VALUE:ORIGINAL COST NEW PLEASE LIST ANY ADDITIONAL BOATS OR DINGHYS:
BOAT LIABILITY LIMIT
UNINSURED BOATERS LIABILITY
MEDICAL PAYMENTS
PLEASE DESCRIBE YOU BOAT NAVIGATION AREAS. IF LEFT BLANK, YOUR QUOTE WILL PRESUME ALL INLAND WATERWAYS AND THE ATLANTIC NORTH COAST BETWEEN PORTIONS OF MAINE AND NEW JERSEY. PLEASE SPECIFY IF YOU NEED A BROADER NAVIGATION AREA:
PRIOR INSURER:PRIOR POLICY #PRIOR POLICY EXPIRATION
PRIOR POLICY #PRIOR POLICY EXPIRATIONANY DRIVERS WITH A DUI or DWI IN THE PAST 5 YEARS
BOAT CLAIMS IN THE PAST 5 YEARS
DO YOU NEED COVERAGE FROM PERSONAL EFFECTS: HOW MUCH:
DO YOU NEED COVERAGE FOR FISHING EQUIPMENT: HOW MUCH:
DO YOU USE THE BOAT FOR ANY TYPE OF BUSINESS USE: EXPLAIN:
DO YOU EMPLOYEE A SHIP CAPTAIN OR CREW: EXPLAIN:
317 Pequot Avenue
PO Box 528
Southport CT 06890
203-255-2877 P
203-254-8427 F
