Agent Quote Form

Fields in bold are required

Agent Information

Agency Name

Agent Contact Name

Agency Address

Agency City, State Zip

Agency Contact Phone Number

Agency Contact Email Address

Boat Owner Information

First Name

Last Name (or Company)

Telephone

Address

City

State

Zip

E-mail

Date of Birth (mm/dd/yyyy)

Dwelling

Marital Status

Years of Boat Ownership

Length of Most Recent Boat ((Put 0 if First Boat Owned))

Claims/Accidents on Any Boat?

If Yes, please explain (Include dates and amounts paid.)

Vessel Details

Manufacturer

Model

Year

Length

Purchase Price

Previously Untitled?

Navigation Area

Type of Boat

Main Engine Information

Engine Type

Fuel Type

Number of Engines

Maximum Horsepower (per engine)

Mooring Location

Mooring Address or Marina Name

Mooring City

Mooring County/Parish

Mooring State

Mooring Zip

Insurance Coverage Requested

Hull & Machinery Value

Trailer Value

Dinghy/Tender Value

Liability Limit

Deductible

Personal Effects

Towing

Will Vessell Need a Lay Up?

Yes

Type of Lay Up

Afloat

Ashore

N/A

Please attach any documents you think will be helpful in obtaining the most competitive quote for your customer.

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