Yacht/Boat Insurance Quote Form

Please complete the following form if you are interested in receiving a marine insurance quote.

Insurance Information:
Name Insured:
Address:

City:	State: Zip:
Phone:
E-mail:
Current Company:
Expiration Date:
Watercraft:
Use:
Year:
Make:
Model:
Length:
Max Speed:
Horsepower:	Twin: Single:
Fuel:	Diesel Gas Aux
Moored/Location:
Laid Up/Location:
Lay-Up Dates:	From: To:
Navigation Limits:
Trailer:
Year:
Manufacturer:
Owner Record:
Years of Boating Experience:
Date of Birth:
Occupation:
Losses in Last Five Years:
Moving Traffic Violations: (Last Five Years)
Limits:
Hull Market Value:	$
Deductible:	(Min. $250 Sailboat/$300 Powerboat)
Dinghy:	$
Liability Limit:	$
Trailer:	$
Personal Effects:	$

Northeast Aviation & Marine Insurance Brokers
Schenectady, NY: 1.800.544.5656
Brookhaven Airport, Long Island, NY: 1.800.544.5656