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We only accept inquiries for insurance written in New York State

Personal Information
Name:
Address:
City:	State:   Zip:
Day Phone:	Night Phone:
Best Time To Call:	AM   PM
Email Address:

 

Current Boat/Watercraft Insurance Information
Company Name (not agency):
Policy Expiration Date:	Premium Amount: $
Term:	6 Months   1 Year   Other:

 

Coverages
(input only for those desired)
Type	Sums Insured	Type	Sums Insured
Hull- Physical Damage	$	Tender / Dinghy	$
Liability Coverage	$	Crew Liability	$
Owner / Operator M&C	$	Medical Payments	$
Commercial Passenger Liability	$	Uninsured Boater	$
Trailer	$	Personal Property	$
Non-Emergency Towing	$	Other	$

 

Vessel Information
Vessel Name:			Manufacturer/Model:
Year	Length	Date Purchased	Purchase Price $	Present Value $	Max Speed mph	Registration #
Hull Identification #:			Waters to be navigated:
Tenders or Dinghies:			Storage Address (Street, City, Co., St.): LAID UP: From: to On Shore Afloat
Stored on Trailer: Y   N Will be trailered over 100 miles: Y   N

 

Equipment
(please select ALL equipment on your Boat/Watercraft)
Bilge Pumps		CO2/Halon System		Aux Generator, Diesel
EPIRB		Fume Detector		Aux Generator, Gas
Sonar		Fire Extinguishers		Other (list below)
Depth Sounder		Cooking Stove
LORAN/ Direction Finder		Engine Alarm
GPS		Anti-theft Devices
Radar		Life Raft
SATNAV/ OMEGA		Ship to Shore Radio

 

Miscellaneous
(please check ALL that apply)
Primary Power		Type of Hull		Hull Material		Fuel Tank
Sail		Sailboat		Wood		Metal
Outboard		Performance		Metal		Fiberglass
Inboard		Runabout		Fiberglass
Inboard/ Outdrive
Other

 

Engine/Outboard Motor Information
(please complete for each engine)
Eng	H.P.	Gas	Diesel	Year	Date Purchased	Purchase Price	Present Value
1						$	$
2						$	$
3						$	$
	Manufacturer/Model					Serial Number
1
2
3

 

Trailer Information
Year	Date Purchased	Purchase Price $	Present Value $
Manufacturer/Model:		Serial #:

 

Operators
(always list insured as Operator #1)
#	Name	DOB	Auto DL #	State	Social Security #	USCG/Power Squadron Certificate
1
2					n/a
3					n/a
#	Auto Violations/Suspensions in last 5 years:					Years of Boat Ownership:
1
2
3

 

Boat/Watercraft Usage
#	Explain all YES responses in REMARKS	Yes/No	#	Explain all YES responses in REMARKS	Yes/No
1	Is the boat chartered to others with captain?	Y N	6	Is the boat used commercially or for business purposes?	Y N
2	Is the boat chartered to others without captain?	Y N	7	Does the applicant employ a paid crew? If so how many?	Y N
3	Is the boat used for racing?	Y N	8	Was any operator involved in a marine loss in the last 10 years (insured or not)?	Y N
4	Is the boat used for water skiing or diving?	Y N	9	Was any coverage declined, cancelled or non-renewed during the last 5 years?	Y N
5	If the boat is used for fare paying passenger charters, what is the average number of passengers per trip?     Number of trips per year?
REMARKS

Additional Comments

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