Forms :: Boater's Choice Insurance ::

MarineMax_Dealer_Quick_Quote_Form

Fields marked with * are required.

Dealer/Agent Information

* Dealer/Agent Name:

Dealer/Agent Address:

Dealer/Agent City:

Dealer/Agent State:

Dealer/Agent Zip:

* Dealer/Agent Contact Name:

* Dealer/Agent Contact Number:

Dealer/Agent Fax Number:

Boat Owner Information

* First Name:

Middle Initial:

* Last Name (or company):

* Telephone:

Fax:

* Address:

* City:

* State:

* Zip:

Dwelling:

Homeowner
Rent
Live with Parent
Other

* Date of Birth:

Marital Status:

Single
Married
Widowed

SSN:

E-mail Address (of customer):

* Is this the first boat owned?:

* Years Boat Ownership:

* Length of Most Recent Boat:

* Claims/Accidents on Any Boat?:

If Yes, please explain (including dates and amounts paid)::

Current Insurance Company:

Current Premium:

Expiration Date Current Policy:

Vessel Details

* Manufacturer:

* Model:

* Year:

* Length:

Hull ID Number:

* Date Purchased:

* Purchase Price:

* Previously Untitled?:

* Navigation Area:

* Nav. Limit:

* Type Of Boat:

Main Engine Information

* Engine Type:

* Fuel Type:

Engine Serial Number:

* Manufacturer:

* Number of Engines:

* Maximum Horsepower (per engine):

* Maximum Speed:

Mooring Location

* Mooring Address:

* Mooring City:

* Mooring County:

* Mooring State:

* Mooring Zip:

Insurance Coverage Requested

* Hull & Machinery Value:

Trailer Value:

Dinghy/Tender Value:

* Liability Limit:

Deductible:

* Personal Effects:

* Towing:

Will Vessel Need a Lay Up? :

Type of Lay Up:

Lay Up Length (Months):

* Has the customer's boat insurance been cancelled or non-renewed in the last 5 years for any reason?:

If so, please provide details:

Leinholder Information (including address):

Notes To Underwriter:

Date: If Customer Requests Binding:

Florida Only

Employer (if applicable):

Employer City / State (if applicable):

List any other residences owned by customer: