MARINE INSURANCE FORM

Welcome to Stacks Marine Insurance – Let’s Protect Your Vessel!

YOUR PREMIER AGENCY FOR MARINE INSURANCE - OFFICE@STACKSBROKERAGE.COM - 754-212-4459
Name or LLC

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address (IF DIFFERENT FROM ABOVE)
Do you own, rent, or have a business more than 4 hours or 150 miles away from your vessels mooring location?

Other
PHONE NUMBER
EMAIL ADDRESS
Occupation
Date of Birth
Drivers License Number
Marital Status
GENDER
HOMEOWNERSHIP

Other
Year of Vessel
Length of Vessel
Make of Vessel
Model of Vessel
HULL ID #
Date of Purchase
Purchase Price (can be different from insured value)
Will vessel be for sale within the next 3-6 months?
Number of Engines
Make of Engines
Horsepower of Each Engine
Model Year of engines
Model of Engines
Type of Engine (if other, please specify below)
Other Type of Engine
Engine Serial Numbers (IF MULTIPLE, PLEASE PUT SLASH "/" BETWEEN)
Fuel Type
Hull Material
Do you have a current survey for your vessel? If YES please send to taylor@stacksbrokerage.com
GPS TRACKING

Other
Have you owned or operated watercraft previously?
What Watercraft have you owned OR operated previously & for how long? Please specify (I.E. OWNED 24FT COBIA - 6YR)
Any claims or losses in the past 5 years on insurance?
How will Watercraft be used

Other
Any Accidents or Tickets (I.E. DUI / MAJOR ACCIDENT/ VEHICULAR HOMICIDE / RECKLESS DRIVING)
Have you taken any additional safety courses or do you have a captains license?

Other
ADDITIONAL EXPERIENCE? (USCG SAFETY COURSE, USCG CAPTAINS LICENSE, BOATERS SAFETY COURSE, POWER SQUADRON?)
ADDRESS WHERE WATERCRAFT IS KEPT IF DIFFERENT FROM HOME ADDRESS (IF DIFFERENT, PLEASE SPECIFY WHOLE ADDRESS AND MARINA OR LOCATION NAME)
HOW IS WATERCRAFT STORED
Will watercraft be financed? If so, please specify bank or put N/A if unsure of lender or NO if paid cash
Additional Insured (I.E. MARINA, FAMILY MEMBER, FRIEND THAT WILL NEED TO BE ON THE POLICY)
Would you like your trailer insured?
Make of trailer
Value of trailer
Year of Trailer
Serial Number of Trailer
INSURED VALUE OF WATERCRAFT (MINUS TRAILER)
P&I / UNINSURED BOATER LIABILITY LIMITS
P&I / UNINSURED BOATER LIABILITY LIMITS
MEDICAL PAYMENTS
PERSONAL EFFECTS
BAHAMAS COVERAGE REQUESTED
BEST TIME FOR US TO REACH YOU
HOW DID YOU HEAR ABOUT US?
ADDITIONAL COMMENTS / COVERAGE REQUESTS / QUESTIONS
Interested in auto, home, business, or jewelry coverage too? You could save $$ by combining your policies.
Which Agent assisted you?
Signature
AGENCY NAME (if applicable)
SMS Opt-In
Should be Empty:

Welcome to Stacks Marine Insurance – Let’s Protect Your Vessel!