New York and Massachussetts Boat Insurance - Free NY and MA Boat and Watercraft Insurance Quotes from Long Island Boat Insurance.com

B O A T Q U O T E - C L I E N T I N F O R M A T I O N

OPERATOR / TITLE OWNER
FULL NAME

DATE OF BIRTH MONTH, DAY, YEAR	DRIVER'S LICENSE STATE

EMAIL ADDRESS	CONTACT PHONE NUMBER


MAILING ADDRESS
STREET ADDRESS:
APARTMENT/SUITE #:
CITY:
STATE:
POSTAL/ZIP CODE:

EXPERIENCE
# OF YEARS OWNING BOATS:
LENGTH & MAKE OF PRIOR BOATS OWNED

# OF YEARS OPERATING BOATS:
LENGTH & MAKE OF PRIOR BOATS OPERATED

ANY PRIOR BOATING LOSSES?
IF YES, PROVIDE DESCRIPTION, DATE & AMOUNT PAID :

BOATING EDUCATION

B O A T I N F O R M A T I O N

VESSEL TYPE

(Note: Vessels 26' and up will require an out of the water survey to issue a quote. We cannot write insurance on boats built prior to 1999.)

YEAR BUILT

LENGTH (FEET)

BOAT MAKE/MANUFACTURER

BOAT MODEL

BOAT TYPE

HULL TYPE

BOAT USE

GENERAL NAVIGATION AREA

BOAT ENGINE SPECS

ENGINE TYPE

# OF ENGINES

ENGINE MANUFACTURE

FUEL TYPE

HORSE POWER PER ENGINE

LAY-UP INFORMATION / WINTERIZE

Is boat hauled for winter months?

If Boat Laid Up, please list Boat Lay-Up Dates
PROVIDE THE MONTH AND DATE THE VESSEL WILL BE OUT OF THE WATER

MONTH

DAY

OUT OF THE WATER:

IN THE WATER:

Boat Lay-Up TYPE

SAFETY EQUIPMENT

CHECK ALL THAT APPLY

VHF	GPS	EPIRB	RADAR
AUTO CO2	PLOTTER	DEPTH SOUNDER
VAPOR DETECT		BURGLAR ALARM

DOES THE BOAT HAVE AN AUTOMATIC FIRE EXTINGUISHING SYSTEM?

MOORING LOCATION & INFORMATION
STATE	COUNTY	CITY	POSTAL CODE

STREET ADDRESS

IS THE VESSEL MOORED MORE THAN TWO HOURS DRIVING TIME DISTANCE FROM THE OWNER'S PRINCIPAL RESIDENCE?

IS THE VESSEL MOORED IN ANY OF THE 5 BOROUGHS OF NEW YORK?


BOAT VALUE
TOTAL PURCHASE PRICE BOAT, MOTORS, EQUIPMENT		PURCHASE DATE MONTH, DAY, YEAR

P O L I C Y I N F O R M A T I O N & C O V E R A G E S

CURRENT INSURER
Current INSURANCE COMPANY (REQUIRED, if none, say "none")

HAS INSURANCE EVER BEEN CANCELLED OR DENIED TO YOU?

POLICY EXPIRATION DATE		PREMIUM

COVERAGE

AMOUNT

DEDUCTIBLE

HULL / MACHINERY
INCLUDED O/B & EQUIPMENT

P & I LIABILITY

NOT APPLICABLE

MEDICAL PAYMENTS

NOT APPLICABLE

UNINSURED BOATER

NOT APPLICABLE

PERSONAL EFFECTS
$500 MINIMUM

$250

TENDER / DINGHY

Value $

TRAILER

Value $

OPTIONAL COVERAGES

	HURRICANE HAUL OUT REIMBURSEMENT
	$500 ELECTRONICS DEDUCTIBLE
	FISHING EQUIPMENT. . .

THE FINE PRINT: BOAT AND OUTBOARD DEDUCTIBLES ARE BASED ON A PERCENTAGE OF THE
HULL VALUE AND HAVE A DEFAULT VALUE OF $100.

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A D D I T I O N A L C O M M E N T S

* "In connection with this application for insurance, we may review your credit report or obtain or use a credit based insurance score based on the information contained in that report. We may use a third party in connection with development of your insurance score."
CHECK THIS BOX FOR QUOTE RELEASE - This information has been reviewed with the customer and agreed upon.

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