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On-Line Boat & Jet Ski
Insurance Quote Form
One Simple Form - takes only 2-3 Minutes!
Or call us now at (305) 643-2333


Your Personal Data

Your Name:
Street Address:
City:
State: (Must be Florida)
Zip Code:
E-Mail (REQUIRED):
E-Mail again for accuracy:
Phone:
Fax (optional):
 
Marital Status:
Single Married
Homeowner?
Yes No
 
Boat Currently Insured?
(If yes, list carrier, and # of years
continuous. If none, type N/C)
 
Is this Boat Co-owned?
(If yes, list all owners names)


OPERATOR INFORMATION #1
Name: Birthdate:
Sex (M/F): # Years U.S.
 Licensing:
Occupation: Drivers License#
Be specific to tell if accidents are "at-fault" or "NOT-at-fault" - (carriers require proof on NOT-at-fault accidents); Also, be specific as to TYPE of violations, and approximate DATES of each in the fields below:
Number & Type of Accidents last 3 years: Number & Type of MINOR violations last 3 years:
Number & Type of MAJOR violations last 3 years: Number of Years
Boating Experience:


OPERATOR INFORMATION #2 (if none, leave blank)
Name: Birthdate:
Sex: # Years U.S.
 Licensing:
Occupation: Drivers License#
Be specific to tell if accidents are "at-fault" or "NOT-at-fault" - (carriers require proof on NOT-at-fault accidents); Also, be specific as to TYPE of violations, and approximate DATES of each in the fields below:
Number & Type of Accidents last 3 years: Number & Type of MINOR violations last 3 years:
Number & Type of MAJOR violations last 3 years: Number of Years
Boating Experience:


VESSEL & UNDERWRITING INFORMATION
Year of Boat: Make & Model
(be specific):
Hull ID number: Boat/Yacht name:
Date Purchased: Country of Registration
Boat Length: Hull Type
(wood, Metal,
fiberglass, etc):
Boat Type Power
Sail
Multi-hull
House boat
Cabin Cruiser
Fishing
Runabout
Commercial
Yacht
Boat/Yacht Use: Personal/Private Racing
Charter
Captain Charter
ENGINE INFORMATION
# of Engines Engine Year
Max. Speed
(in MPH):
Market Value: $
Engine #1 Serial # Engine #2 Serial #
 
Engine Make/model: Engine Type:
(Inboard, I/O, Jet)
 
Engine Horse
Power:
Fuel Type:
(Gas, Diesel, etc.)
Fuel Tanks Metal
Fiberglass
Auxilary Generator Diesel
Gas
 
Trailer Cov.
Needed?
Yes No Yr./Make/Model
of Trailer:
 
Trailer Value: $ Address where boat moored or stored?
 NAVIGATION/SAFETY EQUIPMENT NFORMATION

Fire Extinguisher
Engine Alarm
Fume Detector

VHF Radio
Radar
Sat Nav
RDF
GPS
Depth Finder
Theft Alarm
Auto Pilot
Compass
Describe waters
boat taken on?
Describe boat
general usage?
(fishing, ski, etc.)


VESSEL COVERAGES:
Limits of
Liability:
$15/30 BI / 10 PD $25/50 BI / 15 PD
$50/100 BI / 25 PD $100/300 BI / 50 PD
$250/500 BI / 100 PD
 
Hull Coverage: NO Coverage $250 Deductible
$500 Deductible $1000 Deductible
 
Water Ski
Medical Coverage?
Yes No   Uninsured
  Motorists Cov.?
Yes No
 
Comments or Remarks:
(List additional drivers,
special coverages, etc. here)


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