Insurance

Yachts For Sale

INSURANCE QUOTE

We would like to provide you with a free, no obligation yacht/boat insurance quote from Cox Insurance Sevices. Please note that this quote will only be as accurate as the information that you provide us.

General Information

Name: Last, First, MI.
Address:
City:	State: ZIP:
County:	Email:
Home Phone :	( )
Work Phone :	( )
Best time to call:	AM/PM

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

Coverage's
(include only for those insurances required)
Type	Sums Insured	Type	Sums Insured
Hull- Physical Damage	$	Tender / Dinghy	$
Liability Coverage	$	Medical Payments	$
Non-Emergency Towing	$	Uninsured Boater	$
Personal Property	$	Other	$

Vessel Information

Vessel Name:

Manufacturer/Model:

Year

Length

Date
Purchased

Purchase
Price
$

Present
Value
$

Max
Speed
mph

Waters to be navigated: salt water, fresh water or both

Tenders or Dinghies:

Storage Address (Street, City, Co., St.):

LAID UP:
From: to

On Shore
Afloat

Stored on Trailer:
Y N

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	Plastic
Inboard/ Outdrive

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

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

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

Boat/Watercraft Usage
#	Explain all YES responses below	Y/N	#	Explain all YES responses	Y/N
1	Is the boat used for racing?	Y N	2	Was any operator involved in a marine loss in the last 3 years (insured or not)?	Y N
3	Is the boat used commercially or for business purposes?	Y N	4	Was any coverage declined, cancelled or non-renewed during the last 3 years?	Y N
REMARKS - Please explain any "Yes" Responses From This Section

Additional Comments

Please include any notes you feel might be appropriate for this quotation. If you have additional information and there was not enough fields above, such as additional operators, coverages, etc..., please enter them here.

When Finished - Please click the "Submit " button to send your quote request.