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All Marine Insurance
Quote Request Form (you may use computer Tab key between fields) |
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Bruce V. Schneider
Associates, Inc. | |
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All Marine
Insurance Agency
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Call Us
631.698.3558 |
800.224.1707 |
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Fax Us
631.698.6128
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| Preparer's / Referrer's Information |
| Who Are You? | |
| Referred By (Person's Name) | |
| Referred by (Company) | |
| Phone Number (if known) | |
| Email Address (if known) | |
| Fax Number (if known) | |
| | | Source of Submission | WEB |
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General Information About Insured | | |
| Will This Vessel Be Corporately Titled?
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| Full Name of Vessel Owner | | Date of Birth | |
| Street Address | | City | |
| State | | Zip Code
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| Phone Number | | Email Address | |
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| Years as Boat Operator | | Years as Boat Owner | |
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| Safety Course Completed
(A copy of your certificate is required) | | Occupation | |
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| Driver's License Number | | MVR Driving Record
Last 5 Years | |
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| Length and Make Prior Vessel
Owned 1 | | Years Owned | |
| Length and Make Prior Vessel Owned 2 | | Years Owned | |
| Length and Make Prior Vessel Owned 3 | | Years Owned | |
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| If No Prior Boats Owned,
List Length and Make of
Other Vessels Operated
| | Years Operated | |
| Length and Make Prior Vessel Operated 2
| | Years Operated | |
| Length and Make Prior Vessel Operated 3 | | Years Operated | |
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| Boat Losses/Claims in
past 5 years (If Any:
Please Explain. Include
Date and Amount) | | | |
Vessel / Engines / Storage / Usage Information |
| Purchase Date | | Purchase Price
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| Please list Bank/Lienholder
Name and Address
(if applicable) | | If Vessel Is Currently Insured,
Please List Carrier Name | |
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| Vessel Year | | Manufacturer | |
| Vessel Model Number | | Vessel Type | |
| Vessel Length | Feet Inches | Vessel Weight (for High Performance boats only) | lbs. |
| Hull Type | | Hull Material | |
| Hull ID Number | | | |
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| Engine(s) year | | Engine(s) Manufacturer | |
| Number of engines | | Engine Horsepower EACH | |
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| Engine Type | | Fuel Type | |
| Engine Serial Numbers | | | |
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| Trailer Year | | Trailer Manufacturer | |
| Trailer Serial Number | | | |
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| Vessel Top
Capable Speed (mph) | | General Navigation Area | |
| Intended Use | | In Season Vessel Location | |
| In Season Vessel Address
(City, State, Zip Code, County) | | Layup Location | |
| Layup Start Date
(if applicable) | | Layup End Date
(if applicable) | |
| | | Layup Method | |
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Safety / Anti-Theft Equipment (credits may apply for each item checked) |
| Compass | Auto-fire system | GPS | Fume detector |
| Depth Finder | Outdrive Locks | Radar | CO2 detector |
| VHF Radio | Prop locks | EPIRB | Smoke alarm |
| Anti-theft alarm | Trailer locks | | |
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Coverage / Limits Requested (standard limits may apply)
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Quote Liability Coverage Only
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| Boat and Engine(s) Value $ | | Trailer Value $ | |
| Liability Limit $ | | Deductible amount $ | |
| Personal Property limit $ | |
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| Medical payments limit $ | | Towing $ | |
| Uninsured Boater limit $ | | Fuel Spill Coverage | |
| Dinghy / Tender value $ | |
| Water Sports Coverage | | Other Coverage
Requests | |
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| How Many Vessels Being Quoted For This Insured? | | | |
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| Additional Comments |
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