| Owner: * |
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| Address: * |
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| Address: |
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| City, State, Zip: |
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| Daytime Phone: * |
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| Evening Phone: |
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| Email: * |
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| Birth Date (MM/DD/YYYY): |
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| Years of Boating Experience: |
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| Present Insurer: |
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| Expiration Date: |
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| Current Premium: |
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| Number of claims paid out in the last 3 years: |
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| If number of claims >3 please explain: |
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| Prior Boat Owned 1: |
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| How long was boat 1 owned?: |
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| Prior Boat Owned 2: |
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| How long was boat 2 owned?: |
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| Boat Type Make: |
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| Model: |
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| Year Built: |
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| Length: |
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| Engine Type: |
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| Engine Make: |
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| Engine Year: |
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| Hull Value: |
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| Liability Limit: |
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| Medical Payments: |
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| Personal Effects: |
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| Deductable: |
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| Marina/Mooring location summer: |
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| Marina/Mooring location winter: |
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| Lay-up period: (ie. 11-01 to 04-01): |
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| Is boat stored on land or water during lay-up?: |
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Construction:
Total horsepower of boat: |
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| Fuel: |
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Do you have a tender?
If yes, value and HP of engine: |
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| VHS Radio?: |
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| Auto Halon?: |
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| Depth Finder?: |
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| Radar: |
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| Water Navigated: |
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| No. of months navigated: |
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| Has boat been surveyed?: |
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| If surveyed, how long ago?: |
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| How many in hired crew?: |
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Chartered?
If chartered, bareboat or captained?: |
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| How did you hear about MMI?: * |
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I agree that completing this form
will process my request for an
insurance quote.
No coverage is in effect until bound by an insurance carrier. |
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