REQUEST A QUOTE - BOAT / YACHT / MARINE INSURANCE IN FLORIDA

First Name:

Last Name:

Phone Number:

Fax:

Email:

Address:

City:

State:

Zip:

Is this a new purchase? 

yes no

If yes, Broker's Name:

Estimated purchase date :

Current Insurance Company:

Current Premium:

Current Coverage Amount:

Expiration Date:

Current Survey ?

yes no

Survey Date:

Name of Surveyor :

Year:

length:

Builder:

Model:

Vessel Type:

Hull Material?

fiberglass aluminum inflatable wood steel

Fuel Tank:

fiberglass metal

Number of Motors :

Total Horsepower :

Propulsion Type:

outboard inboard/outboard inboard jet non-power sail

Watercraft Use:

pleasure racing business/commercial rented/chartered live-aboard >

Is there a Tender or a Dinghy ?

yes no

If yes, please describe:

Amount of coverage for the Dinghy:

Trailer?

yes no

Does Coverage include Trailer ?

yes no

Vessel Flag:

Vessel Name:

Hull ID # :

Registration # :

Bilge Pumps

Cooking Stove

Flame Detector

CO2 / Halon System

Fire Extinguishers

Anti-Theft Device

Loran/Direction Finder

Depth Sounder

Radar

Sonar

EPIRB

GPS

Engine Alarm

Generator gas diesel

Ship to Shore Radio

SATNAV/OMEGA

Life Raft

Ashore or Afloat:

ashore afloat

Address:

City:

State:

Zip:

Same address as above ? 

yes no

Address:

City:

State:

Zip:

Years of Boating Experience :

Boating Courses :

none U.S. Power Squadron U.S. Coast Guard Auxiliary metal flat concrete tar & gravel

Other Experience or Training :

Owned Boat Since:

Is there a captain?

yes no

Is there a crew?

yes no

If so how many?

Operator's Drivers License #:

Operator's License State:

Address:

City:

State:

Zip:

Mortgagee Name:

Mortgagee Address:

Loan Number :

Loan Balance :