| Through the Kevin E. Severance Insurance Agency |
| Toll Free 800-816-7714 - 281-333-3100 - Fax. 866-796-0610 |
| Vessel Information | |
|
Vessel Year (e.g. 1995) * |
Vessel Make * |
| Vessel Model |
Vessel Length (in feet - e.g. 30) * |
| Vessel Type * |
Hull Const * |
| # of Engines * Engines Year * |
Engine Make * |
| HP (one engine) * |
Engine Type * |
| Fuel * |
Vessel Weight * |
| Tender Information | |
| Tender Year |
Tender Length (feet) |
| Tender Make |
Tender Engine Year |
| Tender Engine HP |
Tender Engine Make |
| Trailer Information | |
|
Trailer Make |
Number of Axles |
| Trailer Year |
|
| Underwriting Information | |
|
Use of Vessel * |
Live Aboard * |
| Date of Purchase (mm/dd/yyyy) |
Purchase Price $ |
| Present Value $ |
Vessel Top Speed (e.g. 28) * |
| Automatic Firefighting System * |
|
| Moorage Location(Name of Marina, Residence) |
|
| Moorage Zip Code |
Moorage City |
| Moorage County |
Moorage State * |
| Navigation Area * If navigating in additional areas, please use comment section below to record additional areas. |
|
| Has vessel been surveyed? |
If surveyed, give date (mm/dd/yyyy) |
| Crew Information | |
|
Paid Captain or Crew * |
No. of paid Captain/Crew members |
| Full time Captain |
|
| Operator Information | |
| Primary Operator | |
| Name * |
Date of Birth (mm/dd/yyyy) or Age * |
| Years Experience (e.g. 25) * |
Boating Courses * |
| Largest previous Boat |
|
| Percent of Use % |
Occupation |
| 2nd operator | |
| Name |
Date of Birth (mm/dd/yyyy) or Age |
| Years Experience |
Boating Courses |
| Percent of Use % |
Occupation |
| Present Insurance Information | |
|
Losses in Last 5 Years * |
Cancelled Insurance in the last 5 years * |
| Loss Date (mm/dd/yyyy) |
|
| If losses in last 5 years or refused insurance, provide details |
|
| Present Insurance Company |
|
| Expiration Date (mm/dd/yyyy) |
Premium $ |
| Coverage Required | |
|
Hull * $ |
Select Deductible Percent * |
| Engine 1 * $ |
If no engines or if included in the hull value, leave as 0 (zero) |
| Engine 2 * $ |
If no engines or if included in the hull value, leave as 0 (zero) |
| Trailer * $ |
If no trailer, leave as 0 (zero) |
| Tender * $ |
If no tender, leave as 0 (zero) |
| Tender Engine * $ |
If no tender, leave as 0 (zero) |
| Personal Effects * $ |
|
| Medical Payments * $ |
Liability Limit * $ |
| Towing * |
Uninsured Boat Owners * $ |
| Comments | |
| We appreciate your business and want you to know we will strive to provide you with the best insurance service in the Industry. |
Toll Free 800-816-7714 - 281-333-3100 - Fax. 866-796-0610
3027 Marina Bay Dr. Suite 309 - League City, Texas 77573