VRP Boat/Yacht Insurance Form

Submitter First Name*

What is your first name? *

Submitter Last Name*

What is your last name? *

Submitter Email*

What is your email address? *

Submitter Phone Number*

What is your phone number? *

Submitter Occupation*

What is your occupation and employer name?*

Owner Marital Status*

What is your marital status?*

Submitter Address

What is your primary home address?

Street Address Address Line 2 City State ZIP Code

Submitter Date of Birth*

Please enter your date of birth.*

Submitter Driver License Number*

What is your driver's license number?*

Submitter License State*

Please select the state where your driver's license was issued.*

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

Are there any additional drivers?

Are there any other owners/drivers of this vessel?

Yes
No

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

Are you in the process of purchasing this vessel? **

Are you in the process of purchasing this vessel? *

Yes
No

What is the purchase price of the vessel?

What type of vessel is it?

What is the total horsepower?

Vessel Maximum Speed

What is this vessel's maximum speed?

Tell us about the hull.

Hull Material	Hull ID #

Tell us about the engine(s).

Engine Type (Inboard, Outboard, I/O)	# of Engines	HP per Engine

Please tell us more about the engine(s).

Engine Manufacturer	Engine Serial # (Optional)

Trailer?

Is there a trailer?

Yes
No

Will you charter this vessel to others?

Yes
No

Is the vessel financed or leased?

Yes
No
Not sure

Please describe the waters that this vessel navigates. (I.e. Lakes, ocean, etc...)

Summer Marina Address

What is the address where the vessel is moored in the summer?

Street Address Address Line 2 City State ZIP Code

How is the vessel stored in the summer?

What is the address where the vessel is moored in the winter?

Street Address Address Line 2 City State ZIP Code

How is the vessel stored in the winter?

Lay-up Period?

Additional Equipment Onboard

Pleas select the additional equipment onboard this vessel.

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?

Previous Vessels Owned

Please list the length, year, make, model, and the number of years you owned your previous boat(s):

Length	Year	Make	Model	# of years owned

Previous Yacht Claims?

Have there been any previous yacht/boat insurance claims?

Yes
No

Do you have a marine survey for this vessel?

Yes
No

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?

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.

I agree*

VRP Boat/Yacht Insurance Form

Boating History & Experience

Documents and Comments

Cecilia Rivera

RiskRevu^TM Newsletter

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VRP Boat/Yacht Insurance Form

Boating History & Experience

Documents and Comments

Cecilia Rivera

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RiskRevuTM Newsletter

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RiskRevu^TM Newsletter