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
Boat Show
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