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845-Insurance.com
39 Maple Ave.
New City, NY 10956
(845) 638-6200
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Boat Insurance Quote Request

Part I: Personal Information
Name
Address
City
State
Zip
Day Time Phone
Evening Phone
Email Address
Date of Birth
Occupation
Employment Type
Driver’s License Status
Years Boating Experience
Accidents Last 5 years	Yes No
If yes, list vehicle, approximate date, at fault or not at fault, and whether damage was over $1000 or under $1000
Violations Last 5 years (including vehicle)	Yes No
If yes, list approximate dates and, type of violation (Speeding, Traffic Violation, DWI, Dricing with Suspended License, Hit and Run, Other)
Marital Status
Part II: Spouse's Information (if unmarried, skip to part III)
Occupation
Employment Type
Driver’s License Status
Years Boating Experience
Accidents Last 5 years	Yes No
If yes, list vehicle, approximate date, at fault or not at fault, and whether damage was over $1000 or under $1000
Violations Last 5 years (including vehicle)	Yes No
If yes, list approximate dates and, type of violation (Speeding, Traffic Violation, DWI, Dricing with Suspended License, Hit and Run, Other)
Part III: Vehicle Information
Currently Insured	Yes No
If yes, Current Company
Current Expiration date
Current liability limits
Self-Described Credit History	Excellent Average Poor
Primary Usage (check One)	1- Great Lakes, St. Lawrence River including but not beyond Quebec, Hudson River down to but not beyond Poughkeepsie. 2- Pacific Ocean, Arctic Ocean, Atlantic Ocean, Gulf of Mexico, Chesapeake Bay, Delaware River and the remaining portions of the St. Lawrence and Hudson Rivers. 3- Inland lakes and rivers in the state of Connecticut, Massachusetts, New Jersey, Pennsylvania, and Vermont. 4- Any other State or remainder of Canada
Number of Boats
List year, make, and model for each boat.
Type of Boat (Runabout, Cuddy, Tunnel, Cabin Cruiser, Canoe, Dinghies, Sailboat, Catamaran, Houseboat, Pontoon, other)
Type of Power (Outboard, inboard, inboard/outboard, jet drive, none)
Purchase Date(s)
Purchase Price(s)
Comprehensive Deductibles
Collision Deductible
Multi-policy discount	Yes No
Preferred Contact Time
Comments…
You may be contacted to verify additional information. For everyone’s courtesy please only submit serious requests.