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Yacht Boat Quote Request 2016-12-13T12:10:34+00:00

YACHT/BOAT INSURANCE
QUOTE REQUEST

We at Hudson & Muma believe that it is important to offer our customers the most up-to-date technology available which will enhance the service they receive. It is because of this commitment that we are offering this form to aid in generating accurate applications and forms quickly and efficiently!

Remember, without complete information, we may be delayed in producing your quote, so please complete ALL applicable fields.

SUBMITTING THIS FORM YOU ARE AGREEING TO THE CONDITION THAT NO MATERIAL CHANGE WILL BE MADE TO YOUR POLICY UNLESS AND UNTIL YOU RECEIVE CONFIRMATION OF THAT CHANGE FROM A HUDSON & MUMA ASSOCIATE OR AN ASSOCIATE THAT THE INSURANCE COMPANY WRITING THE COVERAGE.
* Indicates required fields


Quote Effective Date:

INSURED INFORMATION:

Type of Customer*:
Personal CustomerCommercial Customer









Preferred Method of Contact:

Insured Birth Date*:

Occupation*:

Insured's Marital Status

Insured's Employer:

 


 

Current Insurance:

Current Insurance Company:

If NONE, is this:

Prior Policy Number:

Prior Policy Expiration Date:

Has Your Insurance Ever Been Cancelled or Non-Renewed?
YesNo

If Yes, Why?

 


 

OPERATOR INFORMATION:

Operator Information

Operator 1(Primary Operator):

Operator 1 Name:
Operator 1 License #:
Operator 1 License State:
Operator 1 D.O.B.:
Operator 1 Sex:
Operator 1 Relation to Insured:
Operator 1, Holds USCG License?: YesNo
Operator 1, Boating Courses?: YesNo
Operator 1, Resume Attached?: YesNo

Operator 2 Name:
Operator 2 License #:
Operator 2 License State:
Operator 2 D.O.B.:
Operator 2 Sex:
Operator 2 Relation to Insured:
Operator 2, Holds USCG License?: YesNo
Operator 2, Boating Courses?: YesNo
Operator 2, Resume Attached?: YesNo

Operator 3 Name:
Operator 3 License #:
Operator 3 License State:
Operator 3 D.O.B.:
Operator 3 Sex:
Operator 3 Relation to Insured:
Operator 3, Holds USCG License?: YesNo
Operator 3, Boating Courses?: YesNo
Operator 3, Resume Attached?: YesNo

Operator 4 Name:
Operator 4 License #:
Operator 4 License State:
Operator 4 D.O.B.:
Operator 4 Sex:
Operator 4 Relation to Insured:
Operator 4, Holds USCG License?: YesNo
Operator 4, Boating Courses?: YesNo
Operator 4, Resume Attached?: YesNo

Total # of Paid Crew:

 


 

LOSS INFORMATION:

List any Prior Boat/Yacht/Marine Losses of Owner, Primary Operator Claims or Losses:

 


 

VESSEL & EQUIPMENT INFORMATION:

Year Built:
Length (feet):
Builder/Manufacturer:
Model Name:

Vessel Type:
Purchase Price($):
Purchase Date:
Hull ID/Documentation #:
Vessel's Name:
Maxiumum Speed:
Hull Material:
If Other, Describe:
Last Marine Survey Date:
Mast Material (if sailboat):

Engine/Propulsion Drive System:

Fuel Type:

Number of Engines:[text #-of-Engines]
Engine Manufacturer 1:
Engine Year Built 1:
Engine HP 1:
Engine Serial No. 1:


Engine Manufacturer 2:
Engine Year Built 2:
Engine HP 2:
Engine Serial No. 2:


Engine Manufacturer 3:
Engine Year Built 3:
Engine HP 3:
Engine Serial No. 3:


Engine Manufacturer 4:
Engine Year Built 4:
Engine HP 4:
Engine Serial No. 4:


Equipment (check all that apply):Built-in Auto FireExtinguishing SystemCarbon Monoxide DetectorFume DetectorAlarm/Monitoring System
Alarm/Monitoring System Manufacturer, Model and Type:

 


 

TRAILER INFORMATION:

Trailer Manufacturer:
Trailer Year Built:
Trailer Purchase Date:
Trailer Value:
Trailer Serial Number:

 


 

TENDER/DINGHY INFORMATION:

Tender/Dinghy - NOT Scheduled:YesNo
(Actual Cash value and Vessel Hull Deductible Amount Applies)
Tender/Dinghy - Scheduled:YesNo
Tender/Dinghy Deductible Option:
Tender/Dinghy Loss Settlement Option:
Tender/Dinghy Value included in Hull value: YesNo
Tender/Dinghy Manufacturer:
Tender/Dinghy Year Built:
Tender/Dinghy Model:
Tender/Dinghy Purchase Date:
Tender/Dinghy Value:
Tender/Dinghy Length:
Tender/Dinghy Serial#:
Tender Motor Year:
Tender Motor Manufacturer:
Tender Motor Serial Num:
Tender Motor HP:
Tender Motor Value (outboards only):
Tender Motor Type:

 


 

OPERATION OF VESSEL:

Waters to be Navigated:

Lay up Period FROM/TO:
If Laid Up, Vessel is Decommissioned: Seletc OneAshoreAfloatAfloat With Bubbler
Berth/Mooring Location JUNE-NOVEMBER, Marina Name, Address, CSZ:

Berth/Mooring Type JUNE-NOVEMBER:
If other, describe:
Berth/Mooring Location DECEMBER-MAY, Marina Name, Address, CSZ:

Berth/Mooring Type DECEMBER-MAY:
If other, describe:

VESSEL IS (check all that apply):
If Bareboat Chartered, days per year:
If Chartered with Crew, days per year:
If Chartered with Crew, Max Number of Passengers:

 


 

INSURANCE COVERAGE REQUESTED

Effective Date of Coverage:
PRIMARY COVERAGE:
Property Damage Limit($):
Porperty Damage Deductible($):
Liability Coverage (incl Pollution)($):
Medical Payments (per person)($):
Uninsured Boaters Limit:
Trailer Limit($):
Trailer Deductible($):
Unscheduled Personal Property($):
Unscheduled Personal Property Deductible($):
Towing & Assistance($):
Tender/Dinghy Limit($):
Tender/Dinghy Deductible($):
Owner's Liability to Paid Crew($):

 


 

ADDITIONAL INTEREST(S)

Interest Type 1(select all that apply):

Name and Address 1:

Interest Type 2(select all that apply):

Name and Address 1:


SPECIAL CONDITIONS, OTHER COVERAGES:

 


 

NOTES:

Referred By:

Who Writes Your Life Insurance:

 


 

Attachments:

If you have a sample from the Certificate Holder or certain portions of a contract that specify what is needed, please attach here.


Name of person completing form:*

Confirmation Email Address:*
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