Pleasure Boat Application - Smithwick and Mariners Insurance

Name *

First Last

Business Name

Address *

Street Address Address Line 2 City State ZIP Code

Phone *

Fax

Email *

Quote Information

Occupation(s)

Date of Birth (MM/DD/YYYY)

Years Boating Experience

Years Boat Owned

Boating Certificates/Licenses

Any Claims in last 5 years

Prior Boats Owned – Type, Size, Years Owned

Most Recent

Current Boat

Hull

Purchase Price

Date of Survey (if applicable)

Make

Model

Year

Length

Speed

Construction

Year Purchased

Engine

Make

Model

Year

Horsepower

Engine Type

Engine Fuel

Number of Engines

Equipment

Boat Equipment

EPIRB
Depth Finder
Fume Detector
VHF
Radar
Automatic Halon/CO2
GPS
Loran
Chartplotter

Other Equipment

Boat Usage

Types of Use

Pleasure
Charter
Racing
Commercial

Navigation Area

Mooring Location

If laid up part of the year

When to when

Where

Paid Crew

Yes
No

Coverage Request

Hull and Machinery Limit

Deductible

P&I Liability Limit

Current Insurance Company

Expiration Date

Current Premium

Extended Navigation Details, Remarks, Other Coverage, and Loss Details

For the Agency

Do you have a specific agent at Smithwick and Mariners you are familiar with?

Yes
No

If yes, please provide agent's name.

Do you have a specific office location you prefer to work with?