Watercraft Quote Form

 

First Name

  Last Name 
  Current Address
  Email Address DOB   SSN# 
  Current Company    Expires   Annual Premium $
  Year Make Model Own Vehicle Identification
1      

  
2      

 
  Name DOB Marital License # Accidents Violations
1    

 

 
2    

 

 
Liability Sports Liability Uninsured Boater Med pay Equipment Dinghy/Tender Personal Effects Trailer

Primary Waters of Navigation:                 Other Waters:   
Home Port Location (Include City & State)
Used for water-skiing?               Lay-up Dates           to       
Ashore In Water Will Vessel be used for anything other than private pleasure?    If yes, describe other usage:   
 
Power Squadron CG Auxiliary Yacht Is certificate available?    Paid Captain/Crew  
If not a new purchase, is this vessel held for sale by  this applicant?   
Declined, non-renewed or Cancelled?    (If so, why?)  
If vessel is over 10 years old, do you have a survey?     If yes, date of survey:  
Check if applicable: Halon/CO2 Auto System  Ship to Shore Radio Electronic alarm GPS System Compass
Radar Smoke Detector Fume Detector Bilge Blowers RDF  Propeller/HUB Locks  Chart Plotter
Fire Extinguisher(s) Depth Finder Outboard/Out Drive Locks Trailer Hitch Loran  

 

Auto Commercial Home Motorcycle

Disclaimer:  It is our intent to release quote information only to you and we have taken every step to keep your information private.  "Fallon Insurance Agency , Inc." does not accept  any responsibility for information accidentally viewed by others via the Internet.  Quotes are outlines of available coverage and are not binding in any legal manner.  All quotes are subject to the terms, conditions, provisions, limitations and exclusions of the actual policy issued between the insurance company and yourself.