Hutch Ham Agency, Inc. -- Boat / Watercraft Quote Form

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Boat/Watercraft INSURANCE QUOTE		We would like to provide you with a free, no-obligation boat/watercraft insurance quote. Please provide as much information possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only.

Personal Information
Name:
Address:
City:	State: Zip:
Day Phone:	Night Phone:
Best Time To Call:	AM PM
Email Address:

Current Boat/Watercraft Insurance Information
Company Name (not agency):
Policy Expiration Date:	Premium Amount: $
Term:	6 Months 1 Year Other:

Coverages
(input only for those desired)
Type	Sums Insured	Type	Sums Insured
Hull- Physical Damage	$	Tender / Dinghy	$
Liability Coverage	$	Crew Liability	$
Owner / Operator M&C	$	Medical Payments	$
Commercial Passenger Liability	$	Uninsured Boater	$
Trailer	$	Personal Property	$
Non-Emergency Towing	$	Other	$

Vessel Information

Vessel Name:

Manufacturer/Model:

Year

Length

Date
Purchased

Purchase
Price
$

Present
Value
$

Max
Speed
mph

Registration #

Hull Identification #:

Waters to be navigated:

Tenders or Dinghies:

Storage Address (Street, City, Co., St.):

LAID UP:
From: to On Shore
Afloat

Stored on Trailer:
Y N

Will be trailered over 100 miles:
Y N

Equipment
(please select ALL equipment on your Boat/Watercraft)
Bilge Pumps	CO2/Halon System	Aux Generator, Diesel
EPIRB	Fume Detector	Aux Generator, Gas
Sonar	Fire Extinguishers	Other (list below)
Depth Sounder	Cooking Stove
LORAN/ Direction Finder	Engine Alarm
GPS	Anti-theft Devices
Radar	Life Raft
SATNAV/ OMEGA	Ship to Shore Radio

Miscellaneous
(please check ALL that apply)
Primary Power	Type of Hull	Hull Material	Fuel Tank
Sail	Sailboat	Wood	Metal
Outboard	Performance	Metal	Fiberglass
Inboard	Runabout	Fiberglass
Inboard/ Outdrive
Other

Engine/Outboard Motor Information
(please complete for each engine)
Eng	H.P.	Gas	Diesel	Year	Date Purchased	Purchase Price	Present Value
1						$	$
2						$	$
3						$	$
	Manufacturer/Model					Serial Number
1
2
3

Trailer Information
Year	Date Purchased	Purchase Price $	Present Value $
Manufacturer/Model:		Serial #:

Operators
(always list insured as Operator #1)
#	Name	DOB	Auto DL #	State	Social Security #	USCG/Power Squadron Certificate
1
2					n/a
3					n/a
#	Auto Violations/Suspensions in last 5 years:					Years of Boat Ownership:
1
2
3

Boat/Watercraft Usage
#	Explain all YES responses in REMARKS	Yes/No	#	Explain all YES responses in REMARKS	Yes/No
1	Is the boat chartered to others with captain?	Y N	6	Is the boat used commercially or for business purposes?	Y N
2	Is the boat chartered to others without captain?	Y N	7	Does the applicant employ a paid crew? If so how many?	Y N
3	Is the boat used for racing?	Y N	8	Was any operator involved in a marine loss in the last 10 years (insured or not)?	Y N
4	Is the boat used for water skiing or diving?	Y N	9	Was any coverage declined, cancelled or non-renewed during the last 5 years?	Y N
5	If the boat is used for fare paying passenger charters, what is the average number of passengers per trip? Number of trips per year?
REMARKS

Additional Comments

Please give any additional comments you feel appropriate for this quotation. If you have additional information where there was not enough fields above, such as additional operators, coverages, etc..., please enter them here.

Please click on the "Submit Quote" button to send your quote request.
One of our representatives will respond to your submission as soon as possible.