Universal

Strickland Insurance Brokers
Monthly
Payment
Plan

Members of AICNC

Powerboat Quote Form

Contact Information
Name (required)
Address
Address 2nd line
City
State
Zip
Contact me by Phone E-Mail Fax
EMail (req'd)
Work Phone Best Time
Home Phone Best Time
Fax
Current Insurance Information
Current Insurance Company (Not Agency)
Date Current Policy Expires mm/dd/yyyy
Your Vessels
  Vessel 1 Vessel 2
Year
Length in Feet
Mfg
Model
Max Speed (mph)
Type of Craft


explain if "other"
explain if "other"
Hull Material
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?)
Vessel 1
 
Vessel 2
Anticipated Trips Outside Standard Usage Area
Vessel 1
 
Vessel 2
Live on Board Yes No Yes No
Lay-Up Period Beginning Month
Ending Month		 Beginning Month
Ending Month
Commercial Use Yes No Yes No
Used for Towing Sports
(skiing etc.)		 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)
Trailer Value
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
Operators
Operator Operator Name Date of Birth
(mm/dd/yyyy)
1
2
3
4
Operator Driver License Number Years
Licensed		 Years
Boating
Experience		 Courses
1
If Other
2
If Other
Driving Violations (not boating violations)
Incident Driver Involved Ticket / Violation
 Violation Date
(mm/dd/yyyy)
1
2
3
4
Questions, Comments or Concerns
This is a Request For Quotation Only.
No coverage is in effect until bound by an insurance carrier.

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