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VRP Boat/Yacht Insurance Form
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Submitter First Name
*
What is your first name? *
Submitter Last Name
*
What is your last name? *
Submitter Email
*
What is your email? *
Submitter Phone Number
*
What is your phone number? *
Submitter Occupation
What is your occupation?
Submitter Employer
What is the name of your employer?
Owner Marital Status
What is your marital status?
Select
Single
Married
Divorced
Widowed
Submitter Address
What is your primary home address?
Street Address
Address Line 2
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
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
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Submitter Date of Birth
What is your date of birth?
MM slash DD slash YYYY
Submitter Driver License Number
What is your drivers license number?
Submitter License State
Which state are you 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
Other
Submitter License State/Country Other
What state/country are you licensed in?
Corporately Titled?
Is there a Trust, LLC, or Limited Partnership involved in the ownership of this vessel?
Yes
No
Not sure
Title Corporation Name
What is the name of the Trust, LLC, or Limited Partnership?
Corporation Purpose
Was this Trust, LLC or Limited Partnership established for the sole purpose owning this vessel?
Yes
No
Not sure
Corporation Purpose Description
Please provide a brief explanation of the other purpose(s) for which this Trust, LLC or Limited Partnership exists.
Are there any additional drivers?
Are there any additional drivers?
Yes
No
Driver List
Please enter the requested information for each additional driver.
Full Name
Date of Birth (MM/DD/YY)
Drivers License Number
Drivers License State
Add
Remove
Vessel Information
Who will drive the boat?
I will (The form submitter)
A Paid Helmsman
A Paid Captain
A Paid Captain and Helmsman
Vessel Information
Please provide the following information about your vessel.
Year
Make
Model
Length
Add
Remove
Are you in the process of purchasing this vessel? *
*
Are you in the process of purchasing this vessel? *
Yes
No
Yacht Purchase Price
What is the purchase price?
Yacht Purchase Date
What is the purchase date?
MM slash DD slash YYYY
Vessel Current Value
What is the current value of the Vessel?
Yacht Effective Date
What date would you like coverage to commence?
MM slash DD slash YYYY
Vessel Maximum Speed
What is this vessel's maximum speed?
What is the total horse power?
What is the total horse power?
Tell us about the hull.
Tell us about the hull.
Hull Material
Hull ID #
Add
Remove
Tell us about the engine(s).
Tell us about the engine(s).
Engine Type (Inboard, Outboard, I/O)
# of Engines
HP per Engine
Add
Remove
Please tell us more about the engine(s).
Please tell us more about the engine(s).
Engine Manufacturer
Engine Serial # (Optional)
Add
Remove
Trailer?
Is there a trailer?
Yes
No
Will you charter your vessel to others?
Will you charter your vessel to others?
Yes
No
Is the vessel financed or leased?
Is the vessel financed or leased?
Yes
No
Not sure
Existing Vessel Financing
Is there a lien on this vessel?
Yes
No
Not sure
Please describe the waters that this vessel navigates. (I.e. Lakes, ocean, etc...)
Please describe the waters that this vessel navigates. (I.e. Lakes, ocean, etc...)
Summer Marina Name?
What is the name of the marina/facility where the yacht is moored in the summer?
Summer Location Type
What type of location is the summer marina/facility?
Dock
Mooring Buoy
Trailered
Lift
Rack/Valet Storage
Stands
Other
Lay-up Period?
Lay-up Period?
Nov - Apr
Nov - Mar
Nov - Feb
Nov - Jan
December
Additional Equipment Onboard
Pleas select the additional equipment onboard this vessel.
Monitoring System
GPS
Radar
Depthfinder
EPIRB
CO Detector
Offshore Life Raft
Survival Suits
Auto Fire Extinguisher
VHF
High Water Alarm
Outboard/Outdrive Locks
Weatherfax
Other
Additional Equipment Onboard Other
Please enter any other additional equipment onboard this yacht.
Please select the discounts you may be eligible for.
Please select the discounts you may be eligible for.
Coast Guard Boating Safety Course
Built-in Fire Extinguishing System
Alarm System
Full-Time Captain
Stored in Hurricane Resistant Building
Boating History & Experience
How many years of boating experience does the owner have?
How many years of boating experience does the owner have?
Previous Vessels Owned
Please provide the length, year, make, model, and the number of years you owned your previous boat(s):
Length
Year
Make
Model
# of years owned
Add
Remove
Previous Yacht Claims?
Have there been any previous yacht/boat insurance claims?
Yes
No
Please provide details on any previous yacht/boat claims.
Please provide details on any previous yacht/boat claims.
Do you have a marine survey for this vessel?
Do you have a marine survey for this vessel?
Yes
No
What is the completion date?
What is the completion date?
Are the survey recommendations completed?
Are the survey recommendations completed?
Yes
No
When will the survey recommendations be completed?
When will the survey recommendations be completed?
Documents and Comments
Document upload
Please use this field to upload any relevant insurance documents. (ie. Current policy declarations pages, marine survey, etc...)
Max. file size: 128 MB.
Remarks
Please enter any additional remarks in the space below.
Lead Source
How did you hear about us?
Current customer
Referred by...
Google search
Agency's website
Email newsletter
Facebook
Instagram
Twitter
Other
Referral Source
Please share who referred you to us.
Google Search Term
Please share what you typed into Google.
Lead Source Other
Please share 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.
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.
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Brian Cook
555-555-5555
brian+2@cmfusion.com
My Bio Title
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