Luxury Yacht Insurance Quote Form

by W.R. Hodgens Marine Insurance, Inc.

Yacht Insurance Quote

Please complete the following in as much detail as possible to assure we can provide you with the most competitive rate, or phone us at 1-800-990-WAVE (9283) for an immediate quote.

Full Name:
Address:
City:
State/Province:
Zip code/Postal zone:
Country:
Drivers License State and Number:
Telephone:
Fax:
E-mail:
Occupation:
Date Of Birth:
Years of boating experience:
Size and builder of previous boats owned:
Are course/member certificates available?	Power Squadron USCG Auxillary USCG Captain License Other License
Motor vehicle driving record past 5 years:
Are there other operators of this vessel?	Yes No

VESSEL INFORMATION
NAME OF VESSEL:
YEAR:
MANUFACTURER/BUILDER:
If your builder is not listed above please add your builder here:
MODEL:
TYPE OF VESSEL:
LENGTH:
PURCHASE PRICE OF VESSEL:
DATE OF PURCHASE:
FLAG:	US Foreign
MAXIMUM SPEED:
HULL TYPE:
HULL MATERIAL:
ENGINES:	NUMBER: FUEL TYPE: HORSEPOWER EACH......... MANUFACTURER.............. DRIVE TYPE........................
EQUIPMENT:	AUTO FIRE EXTINGUISHERS

VESSEL USAGE AND LOCATION

PRIVATE PLEASURE PART TIME CHARTER FULL TIME CHARTER

IF CHARTER- MAX. NUMBER PAYING PASSENGERS/GUESTS:
WHERE IS THE VESSEL MOORED?

NAVIGATION LIMITS

Waters navigated next twelve months:

Is vessel ever laid-up?

Yes No

What months is she out of commission?

If laid up, is vessel stored:

Will anyone be living aboard the vessel during the policy period?

Yes No

PRESENT AND PAST INSURANCE INFORMATION
PRESENT INSURANCE CO.:

EXPIRATION DATE OF POLICY:

CURRENT PREMIUM:
OWNED BOATS SINCE:
Have you had any yacht insurance claims in the past 10 years?	Yes No

Please enter the year, amount, and a brief outline of the loss/claim.

COVERAGES REQUESTED
Hull and equipment value:$ Tender/Dinghy $ Year Trailer............ $ Year Survey Available: Survey Date Survey conducted:
LIABILITY COVERAGE (Protection and indemnity)
Paid Crew Number of Paid Crew:

Comments

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LUXURY YACHT I N S U R A N C E
from W.R. Hodgens Marine Insurance, Inc.
2015 SW 20th St., Suite 100	Fort Lauderdale, FL 33315
Ph: 954-523-6867	Fax: 954-523-6488
Toll Free USA: 800-990-WAVE (9283)