All Marine Insurance Rowing Shell Quote Request Form  (you may use the TAB Key between fields)

Preparer's / Referrer's Information




General Information About Insured




Previous Vessel(s) Owned and Operated


Boat Losses/Claims

Example: mm/yyyy

Preparer's / Referrer's Information
Who Are You*
How Were You Referred To Us*
Your Name (Include Agency or Business Name if applicable)*
Your Phone Number*
Your Email Address*
Your Fax Number*

Source of Submission

WEB


General Information About Insured
Full Name of Vessel Owner*

Date of Birth*

Street Address*City*
State*Zip Code*
Phone NumberEmail Address
Years as Boat OperatorYears as Boat Owner
Safety Course Completed
(A copy of your certificate is required)
Occupation
Driver's License NumberMVR Driving Record
Last 5 Years
Social Security Number
Marital Status
HomeOwner Status


Previous Vessels Owned or Operated
Ownership Status:                      
Length and MakeYears Operated 
Length and MakeYears Operated 
Length and MakeYears Operated 
Length and MakeYears Operated 
Boat Losses/Claims
(If Any: please
explain. Include
Date and Amount)


Vessel / Engines / Storage / Usage Information (For Vessel To Be Quoted)
Purchase DatePurchase Price

Please list Bank/Lienholder
Name and Address
(if applicable)

If Vessel Is Currently Insured,
List Carrier Name and Expiration Date
Vessel Year*Manufacturer*
Vessel Model Number*Vessel Type*
Vessel Length* Feet      InchesVessel Weight (for High Performance boats) lbs.
Hull TypeHull Material
Hull ID Number
Engine(s) yearEngine(s) Manufacturer*
Number of engines*

Engine Horsepower EACH*

Engine Type*Fuel Type
Engine Serial Numbers
Trailer YearTrailer Manufacturer
Trailer Serial Number
Vessel Top
Capable Speed (mph)
General Navigation Area
Intended Use

In Season Vessel Address
(City, State, Zip Code, County)

In Season Vessel Location

Out Of Season Vessel Address
(City, State, Zip Code, County)

Out Of Season Layup Location
Layup Start Date
(if applicable)
Layup End Date
(if applicable)
Layup Method


Safety / Anti-Theft Equipment (credits may apply for each item checked)
CompassAuto-fire systemGPSFume detector
Depth FinderOutdrive LocksRadarCO2 detector
VHF RadioProp locksEPIRBSmoke alarm
Anti-theft alarmTrailer locks


Coverage / Limits Requested (standard limits may apply)

Coverage Type Requested:
 

Boat and Engine(s) Value $*
Trailer Value $
Liability Limit $
Deductible amount $
Personal Property $
Dinghy / Tender value $
Towing $
Medical payments limit $
Uninsured Boater limit $
Other Coverage
Requests

Additional Comments

Please add any additional information below and/or explain any "OTHER" responses you gave.
If you would like an additional vessel quoted, please specify it's Year, Make, Model, Engine(s) HP, and Total Value.

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