What is your first name? *
What is your last name? *
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What is your name?
What is your email address? *
What is your phone number? *
What is your occupation and employer name? *
What is your marital status? *
What is your spouse's full name?
What is your partner's full name?
What is your fiancé's full name?
Please enter their occupation.
Please enter their employer.
Please enter their date of birth.
MM slash DD slash YYYY
Please select their gender. *
Please enter your home address. *
Please enter your date of birth. *
MM slash DD slash YYYY
What is your driver's license number? *
Select the state where your driver's license was issued? *
Do you have prior boating experience? *
How many years of boating experience do you have?
Please select the applicable option(s) below.
Please provide the following information about vessels you have owned.
Please provide the following information about vessels you have rented/borrowed and were solely operated by you.
Is there a Trust, LLC, or Limited Partnership involved in the ownership of this vessel?
What is the name of the trust, LLC, or Limited Partnership?
Are there any other owners/drivers of this vessel?
Additional Owners/Drivers
Please enter the second driver's name.
Please enter the driver's license number for the second driver.
Which state is the second driver licensed in?
What is the second driver's date of birth?
MM slash DD slash YYYY
Is the second driver an owner of this vessel?
Will a third driver be listed on this policy?
Please enter the third driver's name.
Please enter the driver's license number for the third driver.
Which state is the third driver licensed in?
What is the third driver's date of birth?
MM slash DD slash YYYY
Is the third driver an owner of this vessel?
Will a fourth driver be listed on this policy?
Please enter the fourth driver's name.
Please enter the driver's license number for the fourth driver.
Which state is the fourth driver licensed in?
What is the fourth driver's date of birth?
MM slash DD slash YYYY
Is the fourth driver an owner of this vessel?
Vessel Information
Please provide the following information about your vessel.
Are you in the process of purchasing this vessel? *
What is the purchase price? *
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.
What is the value of this vessel? (Ie. Insured amount) *
What date would you like this insurance to commence? *
MM slash DD slash YYYY
What type of vessel is it?
Please describe the type of vessel.
Will this vessel be used for water skiing, wake boarding, knee boarding or any other water sports?
What is the vessel's maximum speed?
Tell us about the hull?
Tell us about the engine(s).
Please tell us more about the engine(s).
Is there a trailer?
Will you be registering the trailer?
What is the VIN (Vehicle identification number) for the trailer?
What is the value of the trailer?
Will you charter this vessel to others?
How many days per year will you charter this vessel?
Is the vessel financed or leased?
What is the name of the lien holder?
What is the address of the lien holder?
Please describe the waters that this vessel navigates. (I.e. Lakes, ocean, etc...)
Is your vessel kept at a marina?
What is the name of the marina?
Enter the address where your vessel is kept.
Please select where you keep your vessel when it is not being used.
What is the address where your vessel is kept?
Does this vessel have a 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.
Do you have a marine survey for this vessel?
Please upload the marine survey here. (Optional)
Please select the discounts you may be eligible for.
Have you had any boat insurance claims?
Please enter information about any boat insurance claims below.
Documents and Comments
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.
How did you hear about us?
Please share who referred you to us.
Can you share what you typed into Google?
Please let us know how you heard about us.
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.
Consumer disclosure: By checking the box below you authorize the Agency who supplied this form to you to contact you via phone, email, and text messaging; to save and share with business partners the information you provided; to obtain consumer reports that may include credit-based reports (where legally allowed), public records, claims history, and driving records so that they can give you accurate insurance quotes.
