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* Denotes a required field. Owner Information Salutation Select one... Mr. Ms. Miss Mrs. Dr. Name* A value is required. Address* A value is required. City* A value is required. State* A value is required. Zip Code* A value is required.Invalid format. Phone* A value is required.Invalid format. Best Time to Call Home Work Work Phone Fax Email Address Invalid format. Type of Ownership* Select ownership type Individual Company Partnership Please select an item. If partnership, number of partners Current Insurer Expiration Date Premium $ Vessel Information Type Select vessel type Bow Rider Center Console Cruiser Cuddy Motor Yacht Performance Powerboat Sailboat Sportfish Trawler Multi-hull - Powerboat Multi-hull - Sailboat Other If "Other" is selected, please describe Construction: Fiberglass Aluminum Other construction - please describe Make/Builder* A value is required. Model Year Length Last Survey Select one... No Survey Available Less than 1 year ago Less than 2 years ago Less than 3 years ago More than 3 years ago Survey Type Select one... In Water Out of Water Maximum Speed Purchase Year Purchase Price $ Use of Vessel Principal Mooring/Storage Address Street City State Zip Code County Seasonal Use? Yes No Lay Up Location: City State Lay Up Dates (Month/Day) through (Month/Day) Lay Up Mode Hauled Afloat Afloat with bubbler Navigation Area Select one... Eastport, Maine to Mystic, Connecticut Eastport, Maine to Cape May, New Jersey Eastport, Maine to Virginia-North Carolina border Eastport, Maine to Cumberland Island, Georgia Eastport, Maine to Cedar Key, Florida Eastport, Maine to Cedar Key, Florida and Bahamas Eastport, Maine to Mobile Bay, Alabama Eastport, Maine to Brownsville, Texas Carrabelle, Florida to Mobile Bay, Alabama Carrabelle, Florida to Brownsville, Texas Florida Florida and Bahamas Barnegat Bay Chesapeake Bay Bahamas Caribbean Great Lakes Inland lakes and rivers more than 60 miles from coast West Coast: N 51 degrees to Ensenada Pt. Conception to Ensenada, plus from 4/15 - 10/15 - to Prince Rupert & to Bahia Tortugas South of Pt. Conception to Ensenada CA: Bodega Head to Pt. Sur CA: Bodega Head to Ensenada CA: San Francisco Bay to within 30 mile radius of Mile Rock Puget Sound to N 51 degrees Puget Sound to N 51 degrees, and Alaska 4/15 - 9/15 Oregon Washington Oregon and Washington Other Navigation Area Vessel Use Personal/Pleasure Primary Residence Chartered How Many/Year? Commercial Use (Explain in Comments) Paid Crew/Captain How Many? Scuba Diving Raced Engine Information Engine(s) Select one... One Two Three Manufacturer Model Year HP (each) Engine Type Select one... Inboard Outboard Inboard/Outboard Jet Fuel Type Select one... Diesel Gasoline Safety Equipment Automatic Fire Suppression System Radar Carbon Monoxide Detector Gas Fume Detector Anti-Theft Other Dinghy Information Dinghy Make Length Model Year Dinghy Engine Make HP Year Desired Coverage (indicate dollar amount) Boat (Hull, Machinery and Equipment) Deductible 1% 2% 3% Other % or $ Amount Liability (P & I) $100,000 $300,000 $500,000 $1 Million Other Liability Amount Personal Property $ Medical Payments $ Fishing Gear $ Trailer $ Dinghy & Dinghy Engine $ Towing $ Describe any other coverage desired Amount $ Note: We automatically include coverage for Uninsured Boater and Fuel Spill Liability. Principal Operator Name Date Of Birth Homeowner Married Single Occupation Boating Courses USPS USCGA Other If licensed captain, indicate rating Boat Ownership Yrs. Boating Experience Yrs. Prior Owned Vessels Make Length Year Purchased Year Sold Make Length Year Purchased Year Sold Boat Insurance History Number of claims in last 5 years? Please provide date, dollar amount and detail below. In the past five years, have you had boat insurance cancelled or renewal refused, other than for nonpayment of premium, or because the insurer withdrew from the market? Yes No Please provide detail below. Motor Vehicle Driving Record - past 3 years In the past 36 months, how many violations/at-fault accidents have you had? Select one... None One Two Three or more For each incident, please provide the approximate date (mm/yy) and indicate either at-fault accident or the type of violation: Additional Operator(s) Name Married Single Relationship Date of Birth Yrs. Exp. In the past 36 months, how many violations/at-fault accidents has operator had? Select one... None One Two Three or more For each incident, please provide the approximate date (mm/yy) and indicate either at-fault accident or the type of violation: Name Married Single Relationship Date of Birth Yrs. Exp. In the past 36 months, how many violations/at-fault accidents has operator had? Select one... None One Two Three or more For each incident, please provide the approximate date (mm/yy) and indicate either at-fault accident or the type of violation: Comments Important notice! Certain of our insurers require a consumer report check in connection with rating. If you wish that we not quote with such companies, please so indicate in Comments below.

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