Universal

Strickland Insurance Brokers
Monthly
Payment
Plan

Members of AICNC

Sailboat 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 (feet)
Manufacturer
Model
Type of Craft
Other
Other
Hull Material
Name of Craft
General Information
Purchase Price $ $
Date of Purchase mm/dd/yyyy mm/dd/yyyy
Storage or
Mooring Location
Anticipated Trips
Outside Standard
Usage Area
Live on Board Yes No Yes No
Lay-Up Period 1st Month
Last Month		 1st Month
Last 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
Current CoverageInsurance
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
Oper Driver
License
Number		 Years Licensed Years
Boating Exp		 Courses
1
Other
2

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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