Sailboat Quote

North Carolina Residents Only!

Contact Information...
Name (required)
Address
Address (second line)
City		State	Zip

Please Contact Me Via...	Phone E-Mail Fax
Work Phone		Best Time To Call
Home Phone		Best Time To Call
Fax
E-Mail (required)

Current Insurance Information...
Current Insurance Company (not agency)
Date Current Policy Expires	mm/dd/yyyy

	Vessel 1	Vessel 2
Your Vessels...
Year
Length
Manufacturer
Model
Type of Craft	Other	Other
Hull Materials
Name of Craft
General Information
Purchase Price	$	$
Date of Purchase	mm / dd / yyyy	mm / dd / yyyy
Storage / Mooring Location
Standard Area of Usage (Where is the Vessel Primarily Operated?)
Anticipated Trips Outside Standard Usage Area
Live on Board	Yes No	Yes No
Lay-Up Period	Beginning Month Ending Month	Beginning Month Ending Month
Commercial Use	Yes No	Yes No
Paid Crew	Yes No	Yes No
Equipment / Maintenance
Date of Last Survey	mm / dd / yyyy	mm / dd / yyyy
Drive
Engine(s)
Engine Make
Engine Year
C.I. / H.P. (per engine)
Fuel
Fixed Fire System	Yes No	Yes No
Fume Sniffer	Yes No	Yes No
Requested Coverage Limits
Hull Value (Insuring Amount)
Motor Value (Insuring Amount)
Tender / Dinghy Value
Accessory Value
Physical Damage Deductible
Liability Limit	(applies to all vessels on policy)
Owner Information
Prior Boats Owned
Occupation of Owners
If Multi-Party Ownership, list names of other Owners including Companies.

Coverage Information
Current Insurer
Expiration Date of Current Policy	mm / dd / yyyy
Requested Effective Date	mm / dd / yyyy

Operator	Name	Date of Birth (MM/DD/YYYY)
Operators
1
2
3
4

Operator	Driver License Number	Number of Years Licensed	Years of Boating Experience	Courses
1				If Other
2				If Other

Incident	Driver Involved	Ticket / Violation	Violation Date (MM/DD/YYYY)
Driving Violations (not boating violations)
1
2
3
4

Comments, Questions, or Concerns

This is a Request For Quotation Only.
No coverage is in effect until bound by an insurance carrier.

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