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CGA Boat/Watercraft INSURANCE QUOTE
We would like to provide you with a free, no-obligation quote. Please provide as much information possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only.

Submitting Information
Business Name:
Contact Name:
Street Address:
City:   State:   ZIP:
County:   Email:
Business Phone: Fax:

Application Information Section
Name:
Street Address:
City:   State:   ZIP:
Email:
Phone: Fax:
Email Address:

Current Boat/Watercraft Insurance Information
Company Name (not agency):
Policy Expiration Date:   Premium Amount: $
Term: 6 Months   1 Year   Other:

Coverages (input only for those desired)
Type Sums Insured Type Sums Insured
Hull- Physical Damage $ Tender / Dinghy $
Liability Coverage $ Crew Liability $
Owner / Operator M&C $ Medical Payments $
Commercial Passenger Liability $ Uninsured Boater $
Trailer $ Personal Property $
Non-Emergency Towing $ Other $

Vessel Information
Vessel Name:
 Manufacturer/Model:
 
Year
  
Length
 Date
Purchased
 Purchase
Price
$ 		Present
Value
$ 		Max
Speed
mph		  
Registration #
Hull Identification #:
 Waters to be navigated:
Tenders or Dinghies:
 Storage Address (Street, City, Co., St.):

LAID UP:
From: to 		On Shore
Afloat
Stored on Trailer:
Y   N

Will be trailered over 100 miles:
Y   N

Equipment (please select ALL equipment on your Boat/Watercraft)
Bilge Pumps CO2/Halon System Aux Generator, Diesel
EPIRB Fume Detector Aux Generator, Gas
Sonar Fire Extinguishers Other (list below)
Depth Sounder Cooking Stove
LORAN/ Direction Finder Engine Alarm
GPS Anti-theft Devices
Radar Life Raft
SATNAV/ OMEGA Ship to Shore Radio


Miscellaneous (please check ALL that apply)
Primary Power Type of Hull Hull Material Fuel Tank
Sail Sailboat Wood Metal
Outboard Performance Metal Fiberglass
Inboard Runabout Fiberglass    
Inboard/ Outdrive        
Other        

Engine/Outboard Motor Information (please complete for each engine)
Eng H.P. Gas Diesel Year Date
Purchased		 Purchase
Price		 Present Value
1 $ $
2 $ $
3 $ $
  Manufacturer/Model Serial Number
1
2
3

Trailer Information
Year
 Date Purchased
 Purchase Price
$ 		Present Value
$
Manufacturer/Model:
 Serial #:

Operators (always list insured as Operator #1)
 #  Name DOB Auto DL # State Social Security # USCG/Power Squadron
Certificate
1
2 n/a
3 n/a
# Auto Violations/Suspensions in last 5 years: Years of Boat Ownership:
1
2
3

Boat/Watercraft Usage
 #  Explain all YES responses in REMARKS Yes/No  #  Explain all YES responses in REMARKS Yes/No
1 Is the boat chartered to others with captain? Y
N		 6 Is the boat used commercially or for business purposes? Y
N
2 Is the boat chartered to others without
captain?		 Y
N		 7 Does the applicant employ a paid crew? If so how many? Y
N
3 Is the boat used for racing? Y
N		 8 Was any operator involved in a marine loss in the last 10 years (insured or not)? Y
N
4 Is the boat used for water skiing or diving? Y
N		 9 Was any coverage declined, cancelled or non-renewed during the last 5 years? Y
N
5 If the boat is used for fare paying passenger charters, what is the average number of passengers
per trip?     Number of trips per year?
REMARKS

Additional Comments
Please give any additional comments you feel appropriate for this quotation. If you have additional information where there was not enough fields above, such as additional operators, coverages, etc..., please enter them here.

 
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