Charter Boats Insurance Quote Form

by W.R. Hodgens Marine Insurance, Inc.

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Yacht Insurance Quote

Please complete the following in as much detail as possible to assure we can provide you with the most competitive rate, or phone us at 1-800-990-WAVE (9283) for an immediate charter insurance quote.

APPLICANT'S PERSONAL INFORMATION

Full Name:
Address:
City:
State/Province:
Zip code/Postal zone:
Country:
Drivers License State and Number:
Telephone:
Fax:
E-mail:
Occupation:
Date Of Birth:
Years of boating experience:
Size and builder of previous boats owned:
Are course/member certificates available?	Power Squadron USCG Auxillary USCG Captain License Other License
Motor vehicle driving record past 5 years:
Are there other operators of this vessel?	Yes No

VESSEL INFORMATION
NAME OF VESSEL:
YEAR:
MANUFACTURER/BUILDER:
If your builder is not listed above please add your builder here:
MODEL:
TYPE OF VESSEL:
LENGTH:
PURCHASE PRICE OF VESSEL:
DATE OF PURCHASE:
FLAG:	US Foreign
MAXIMUM SPEED:
HULL TYPE:
HULL MATERIAL:
ENGINES:	NUMBER: FUEL TYPE: HORSEPOWER EACH......... MANUFACTURER.............. DRIVE TYPE........................
EQUIPMENT:	AUTO FIRE EXTINGUISHERS

VESSEL USAGE AND LOCATION

PRIVATE PLEASURE PART TIME CHARTER FULL TIME CHARTER

IF CHARTER- MAX. NUMBER PAYING PASSENGERS/GUESTS:
WHERE IS THE VESSEL MOORED?

NAVIGATION LIMITS

Waters navigated next twelve months:

Is vessel ever laid-up?

Yes No

What months is she out of commission?

If laid up, is vessel stored:

Will anyone be living aboard the vessel during the policy period?

Yes No

PRESENT AND PAST INSURANCE INFORMATION
PRESENT INSURANCE CO.:

EXPIRATION DATE OF POLICY:

CURRENT PREMIUM:
Have you had any yacht insurance claims in the past 10 years?	Yes No

Please enter the year, amount, and a brief outline of the loss/claim.