Use this form to request a marine insurance quote for your insured. In order to give you the best service and the lowest quote, please answer all questions in this form.

Agency name:
Address:
City, State, Zip:
Phone:
Fax:
Email:
Contact person:
Insured's Name:	First Last
Effective Date:
Insurance company:
Prior claims in past 5 years:	No Yes, amount paid
Boat Description Openbow Cuddy Bass Center console Personal Watercraft Other Yacht Description Express Flybridge Trawler Sail Other
Vessel Year Mfg./Model Lgth.
Motor Description Year Mfg. HP Gas Diesel Single Twin No Motor Type of Motor: Inboard/Outdrive Inboard Jet
Outboard Motor Description Year Mfg. HP Single Twin
Trailer Yes No Year Mfg.
Electronic Equipment VHF Radio Depth Finder Loran GPS Radar
Safety Equipment Engine Fire System: Yes No
Navigation Area Inland Lakes & Rivers Coastal Waters Southern California Northern California Other:
Owner Taken Boating Safety Course	Yes No
Owner Over Age of 25	Yes No
Any operator of vessel have more than 2 minor traffic tickets in past 36 months?
	No Yes, # of tickets
Any major convictions?	No Yes
Coverages to be Quoted Hull Limit: Boat Deductible: $100 $250 $500 Yacht Deductible: 1% 2% 3% Other, Outboard Motor(s) Limit: Motor #1 Motor #2 Trailer Limit: Dinghy Limit: Liability: $100,000 $300,000 $500,000 $1,000,000 Other: Medical Payments: $1,000 $5,000 $10,000 $25,000 Uninsured Boater: $10,000 $15,000 $25,000 Other:
Additional information or coverages requested: