West Coast Marine Insurance

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

Consumer Quote

* First Name:

* Last name:

* Address:

* City:

* State:

* Zip:

* Phone:

* Fax:

* Email:

* I prefer to be contacted by:

Phone Fax Email Mail

* Insurance renewal date:

* Current insurance company:

* Prior claims in past 5 years:

Yes, No,
Amount Paid

Vessel Description

Openbow, Cuddy, Bass,
Pontoon, Center Console,
Personal Watercraft, House Boat,
Express, Flybridge, Sail

* Other:

Vessel Description

* Year:

* Length:

* Mfg./Model:

Motor Description

Year:

Mfg./Model:

Type of Motor: Inboard/Outdrive Inboard Jet
Outboard Electric No Motor

Type of Fuel: Gas, Diesel, No Motor

Total Engine(s): Horsepower

Number of Engines: Single, Twin, Tripple

Trailer

Yes No

Electronic Equipment

Type: VHF Radio, Depth Finder, Radar,
GPS,

* Other:

Safety Equipment

Type: Engine Fire System, Fume Detector,
Carbon Monoxide Detector,

* Other:

Navigation Area

Type: Inland Lakes & Rivers, Coastal

* Other:

Location of Vessel

Type: Residence, Storage Yard, Marina,

Owner Taken Boating Safety Course

Safety Course: Yes, No,

Owner Over Age of 25

Age:

Any operator of vessel have more than
2 minor traffic tickets in past 36 months?

Traffic Tickets: Yes, No,

* Other:

Any major convictions?

Convictions: Yes, No,

Coverages to be Quoted?

Hull and Motor Limit:

Hull Deductible: $100, $250, $500, $1000,

1%, 2%, 3%

* Other:

Trailer Limit:

Dinghy / Motor Limit:

Liability: $100,000, $300,000, $500,000,
$1,000,000,

* Other:

Medical Payments: $1,000, $5,000 $10,000
$25,000

Additional information or coverages requested: