Yacht Insurance Quote

PLEASE CALL US AT 800-990-9283 AND WE CAN DISCUSS YOUR PARTICULAR INSURANCE NEEDS, OR FILL IN THE FORM BELOW AND WE WILL RESPOND TO YOU SHORTLY.
*E-mail address required.
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APPLICANT'S PERSONAL INFORMATION

Full Name:
Address:
City:
State/Province:
Zip code/Postal zone:
Country:
Drivers License State and Number:    
Telephone:
Fax:
*E-mail:
Occupation:
Date Of Birth:
Years of boating experience:
Size and builder of previous boats owned:
Are course/member certificates available? Power Squadron USCG Auxillary
USCG Captain License None
Motor vehicle driving record past 5 years:
Are there other operators of this vessel? Yes No

VESSEL INFORMATION

NAME OF VESSEL:
YEAR:
MANUFACTURER/BUILDER:
If your builder is not listed above please add your builder here:
MODEL:
TYPE OF VESSEL:
LENGTH:
PURCHASE PRICE OF VESSEL:
DATE OF PURCHASE:
FLAG: US Foreign
MAXIMUM SPEED:
HULL TYPE:
HULL MATERIAL:
ENGINES: NUMBER: FUEL TYPE:
HORSEPOWER EACH.........
MANUFACTURER..............
DRIVE TYPE...
AUTO FIRE EXTINGUISHERS:

VESSEL USAGE AND LOCATION

PRIVATE PLEASURE PART TIME CHARTER FULL TIME CHARTER
IF CHARTER- MAX. NUMBER PAYING PASSENGERS/GUESTS:
WHERE IS THE VESSEL MOORED?

NAVIGATION LIMITS
Waters navigated next twelve months:
If vessel is south of North Carolina June through November, where navigated and berthed?
Is vessel ever laid-up? Yes No
What months is she out of commission? to
If laid up, is vessel stored:
Will anyone be living aboard the vessel during the policy period? Yes No

PRESENT AND PAST INSURANCE INFORMATION

PRESENT INSURANCE CO.:
EXPIRATION DATE OF POLICY:
CURRENT PREMIUM:
OWNED BOATS SINCE:
Have you had any yacht insurance claims in the past 10 years? Yes No
Please enter the year, amount, and a brief outline of the loss/claim.

COVERAGES REQUESTED

Hull and equipment value:$
Tender/Dinghy $ Year
Trailer............ $ Year
Survey Available: Survey Date
Survey conducted:

LIABILITY COVERAGE (Protection and indemnity)

Paid Crew Number of Paid Crew:

Comments

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UNITED YACHT INSURANCE

by W.R. Hodgens Marine Insurance, Inc.
2015 SW 20th St., Suite 100
Fort Lauderdale, FL 33315
Ph: 954-523-6867 · Fax: 954-523-6488
Toll Free USA:  800-990-WAVE (9283)

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