What is your first name? ** What is your first name? *
What is your last name? ** What is your last name? *
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What is your name? What is your name?
What is your email address? ** What is your email address? *
What is your phone number? ** What is your phone number? *
What is your occupation and employer name? ** What is your occupation and employer name? *
What is your marital status? ** What is your marital status? *
Single Married Domestic Partnership Engaged Divorced Widowed
What is your spouse's full name? What is your spouse's full name?
What is your partner's full name? What is your partner's full name?
What is your fiancé's full name? What is your fiancé's full name?
Please enter their occupation. Please enter their occupation.
Please enter their employer. Please enter their employer.
Please enter their date of birth. Please enter their date of birth.
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Please select their gender. * Please select their gender. *
Please enter your home address. ** Please enter your home address. *
Please enter your date of birth. ** Please enter your date of birth. *
MM slash DD slash YYYY
What is your driver's license number? ** What is your driver's license number? *
Select the state where your driver's license was issued? ** Select the state where your driver's license was issued? *
Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Armed Forces Americas Armed Forces Europe Armed Forces Pacific
Do you have prior boating experience? ** Do you have prior boating experience? *
Primary Insured Years Experience How many years of boating experience do you have?
Primary insured boats owned or rented Please select the applicable option(s) below.
Primary insured previous vessels owned Please provide the following information about vessels you have owned.
Primary insured previous vessels rented Please provide the following information about vessels you have rented/borrowed and were solely operated by you.
Entity Ownership Is there a Trust, LLC, or Limited Partnership involved in the ownership of this vessel?
Entity Name What is the name of the trust, LLC, or Limited Partnership?
Other Owners/Drivers Are there any other owners/drivers of this vessel?
Additional Owners/Drivers Second driver's name Please enter the second driver's name.
Please enter the driver's license number for the second driver. Please enter the driver's license number for the second driver.
Which state is the second driver licensed in? Which state is the second driver licensed in?
Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Armed Forces Americas Armed Forces Europe Armed Forces Pacific
What is the second driver's date of birth? What is the second driver's date of birth?
MM slash DD slash YYYY
Second driver owner? Is the second driver an owner of this vessel?
Will a third driver be listed on this policy? Will a third driver be listed on this policy?
Please enter the third driver's name. Please enter the third driver's name.
Please enter the driver's license number for the third driver. Please enter the driver's license number for the third driver.
Which state is the third driver licensed in? Which state is the third driver licensed in?
Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Armed Forces Americas Armed Forces Europe Armed Forces Pacific
What is the third driver's date of birth? What is the third driver's date of birth?
MM slash DD slash YYYY
Third driver owner? Is the third driver an owner of this vessel?
Will a fourth driver be listed on this policy? Will a fourth driver be listed on this policy?
Please enter the fourth driver's name. Please enter the fourth driver's name.
Please enter the driver's license number for the fourth driver. Please enter the driver's license number for the fourth driver.
Which state is the fourth driver licensed in? Which state is the fourth driver licensed in?
Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Armed Forces Americas Armed Forces Europe Armed Forces Pacific
What is the fourth driver's date of birth? What is the fourth driver's date of birth?
MM slash DD slash YYYY
Fourth Driver Owner? Is the fourth driver an owner of this vessel?
Vessel Information Vessel Description Please provide the following information about your vessel.
Are you in the process of purchasing this vessel? ** Are you in the process of purchasing this vessel? *
What is the purchase price? ** What is the purchase price? *
What date will you be taking possession of the vessel? ** What date will you be taking possession of the vessel? *
MM slash DD slash YYYY
If available, please upload a copy of the bill of sale. If available, please upload a copy of the bill of sale.
What is the value of this vessel? (Ie. Insured amount) ** What is the value of this vessel? (Ie. Insured amount) *
What date would you like this insurance to commence? ** What date would you like this insurance to commence? *
MM slash DD slash YYYY
Vessel Type What type of vessel is it?
Select Power Boat Sail Boat Yacht Fishing Boat House Boat Pontoon Boat Catamaran Other
Please describe the type of vessel. Please describe the type of vessel.
Will this vessel be used for water skiing, wake boarding, knee boarding or any other water sports? Will this vessel be used for water skiing, wake boarding, knee boarding or any other water sports?
Max Speed What is the vessel's maximum speed?
Hull Details Tell us about the hull?
Engine Details Tell us about the engine(s).
Engine Details 2 Please tell us more about the engine(s).
Is there a trailer? Is there a trailer?
Will you be registering the trailer? Will you be registering the trailer?
What is the VIN (Vehicle identification number) for the trailer? What is the VIN (Vehicle identification number) for the trailer?
What is the value of the trailer? What is the value of the trailer?
Charter Will you charter this vessel to others?
Charter Days How many days per year will you charter this vessel?
Financing Is the vessel financed or leased?
What is the name of the lien holder? What is the name of the lien holder?
What is the address of the lien holder? What is the address of the lien holder?
Navigation Area Please describe the waters that this vessel navigates. (I.e. Lakes, ocean, etc...)
Mooring Location Is your vessel kept at a marina?
What is the name of the marina? What is the name of the marina?
Mooring Location Address Enter the address where your vessel is kept.
Please select where you keep your vessel when it is not being used. Please select where you keep your vessel when it is not being used.
What is the address where your vessel is kept? What is the address where your vessel is kept?
Does this vessel have a lay-up period? Does this vessel have a lay-up period?
How is the vessel stored during the lay-up period? How is the vessel stored during the lay-up period?
Please check the boxes of all the conditions below that apply to this vessel while it is laid-up. Please check the boxes of all the conditions below that apply to this vessel while it is laid-up.
Do you have a marine survey for this vessel? Do you have a marine survey for this vessel?
Please upload the marine survey here. Please upload the marine survey here. (Optional)
Discounts Please select the discounts you may be eligible for.
Any boating claims? Have you had any boat insurance claims?
Prior boat insurance claims history? Please enter information about any boat insurance claims below.
Documents and Comments Please use this field to upload any relevant documents. (ie. Current policy declarations pages, marine survey, etc...) Please use this field to upload any relevant insurance documents. (ie. Current policy declarations pages, marine survey, etc...)
Please enter any additional remarks in the space below. Please enter any additional remarks in the space below.
How did you hear about us? How did you hear about us?
Referred by... Current customer Google search Agency's website Email newsletter Facebook Instagram Twitter Other
Please share who referred you to us. Please share who referred you to us.
Can you share what you typed into Google? Can you share what you typed into Google?
Please let us know how you heard about us. Please let us know how you heard about us.
Consent* Disclaimer: This online questionnaire is a tool used to gather information. It is not an application for insurance. No insurance coverage will be bound or put into effect by submitting this form.
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