Name *
DOB *
Address *
City *
State *
Zip Code *
Phone *
Fax
Email *
Occupation
Years Boating Experience *
If Applicable; List All
Vessel Purchase Date *
Vessel Name
Year Built *
Length *
Type *
\nSelect
Sail
Power
Cruise Speed *
Boat Manufacturer *
Mast Material *
\nSelect
Aluminum
Carbon
Wood
Hull Material *
Number of Engines *
Engine HP (Each) *
Engine Manufacturer
Engine Type/Fuel *
\nGas
Diesel
Electric
Auto Extinguish System *
\nSelect
Yes
No
Paid Crew
\nSelect
Yes
No
Primary Moorage Location *
Date Last Surveyed
Market Value *
Purchase Price *
Survey *
\nSelect
In Water
Out of Water
Charter Use? *
\nSelect
Yes
No
If so, Average Time (Days)
Average # of Passengers
Desired Navigational Territory *
Other - Please Specify
Requested Hull Coverage *
Hull Deductible *
\nSelect
1%
2%
3%
Personal Effects $ *
\n2,500
5,000
10,000
25,000
P & I Liability $
\n300,000
500,000
1,000,000
Other - Please Specify
Other - Please Specify
Dinghy & Outboard $ *
How Did You Hear About Us
\nSelect
Latitude 38
Sailing Anarchy
Northwest Yachting Magazine
Catalina Yachts - Mainsheet Magazine
Costa Vallarta Magazine
Vallarta Real Estate Guide
Mariners Marine Directory
MPC Directory
Internet Web Search
Word of Mouth
Other
If Applicable, please fill out the additional information below:
Current Insurance Company
Annual Premium $
Policy Expiration Date
Any marine insurance lost in the last 10 years
\nSelect
Yes
No
If Yes, Specify The Date And Amount
Additional Comments
