Powerboat Quote

Let us quote your boat insurance! You may give us a call or complete the following form to receive a competitive quote. Only complete the fields that pertain to your situation. We respect your personal priviacy. Please review our Privacy Statement.

North Carolina, South Carolina and Virginia Residents Only!

Contact Information...
Name (required)
Address
Address (second line)
City		State	Zip

Please Contact Me Via...	Phone E-Mail Fax
Work Phone		Best Time To Call
Home Phone		Best Time To Call
Fax
E-Mail (required)

Current Insurance Information...
Current Insurance Company (not agency)
Date Current Policy Expires	mm/dd/yyyy

	Vessel 1	Vessel 2
Your Vessels...
Year
Length
Manufacturer
Model
Max Speed	mph	mph
Type of Craft	Other	Other
Hull Materials
Name of Craft
General Information
Purchase Price	$	$
Date of Purchase	mm / dd / yyyy	mm / dd / yyyy
Storage / Mooring Location
Standard Area of Usage (Where is the Vessel Primarily Operated?)
Anticipated Trips Outside Standard Usage Area
Live on Board	Yes No	Yes No
Lay-Up Period	Beginning Month Ending Month	Beginning Month Ending Month
Commercial Use	Yes No	Yes No
Used for Towing Sports (skiing etc.)	Yes No	Yes No
Paid Crew	Yes No	Yes No
Equipment / Maintenance
Date of Last Survey	mm / dd / yyyy	mm / dd / yyyy
Drive
Engine(s)
Engine Make
Engine Year
C.I. / H.P. (per engine)
Fuel
Fixed Fire System	Yes No	Yes No
Fume Sniffer	Yes No	Yes No
Requested Coverage Limits
Hull Value (Insuring Amount)
Motor(s) Value (Insuring Amount)
Trailer Value
Tender / Dinghy Value
Accessory Value
Physical Damage Deductible
Liability Limit	(applies to all vessels on policy)
Owner Information
Prior Boats Owned
Occupation of Owners
If Multi-Party Ownership, list names of other Owners including Companies.

Coverage Information
Current Insurer
Expiration Date of Current Policy	mm / dd / yyyy
Requested Effective Date	mm / dd / yyyy

Operator	Name
Operators
1
2
3
4

Operator	Number of Years Licensed	Years of Boating Experience	Courses
1			If Other
2			If Other

Incident	Driver Involved	Ticket / Violation	Violation Date (MM/DD/YYYY)
Driving Violations (not boating violations)
1
2
3
4

Comments, Questions, or Concerns

This is a Request For Quotation Only.
No coverage is in effect until bound by an insurance carrier.

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