MARINE INSURANCE FORM

YOUR PREMIER AGENCY FOR MARINE INSURANCE

SPECIALIZING IN WATERCRAFT, CENTER CONSOLES & MOTOR YACHTS, BOTH PRIVATE AND COMMERCIAL RISKS TAYLOR@STACKSBROKERAGE.COM // 754-212-4459
Name *

First Name Last Name

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Mailing Address (IF DIFFERENT FROM ABOVE)
PHONE NUMBER *
EMAIL ADDRESS *
Occupation *
Date of Birth *
Drivers License Number *
MARITIAL STATUS

SINGLE MARRIED DIVORCED WIDOWED SEPARATED
GENDER

Male Female
HOMEOWNERSHIP

Own home Rent home Live with parents
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) *
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 (Fiberglass, Aluminum, Steel, Wood, Other)
Do you have a current survey for your vessel? If YES please send to taylor@stacksbrokerage.com

YES NO No but will be getting one
GPS TRACKING

SPOT GOST ATLASTRAX
Have you owned or operated watercraft previously? *

OWNED OPERATED OWNED AND OPERATED NO
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 3-5 years on insurance? *

YES NO
How will Watercraft be used *

PRIVATE PRIVATE WITH LIGHT CHARTER FULL TIME CHARTER CHARTER (BARE BOAT) CHARTER (6PACK) LIVE-ABOARD
Any Accidents or Tickets (I.E. DUI / MAJOR ACCIDENT/ VEHICULAR HOMICIDE / RECKLESS DRIVING) *

YES NO
Have you taken any additional safety courses or do you have a captains license?

USCG Power Squadron Captains license
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? *

Yes No
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

$300,000 $500,000 $1,000,000 $2,000,000
P&I / UNINSURED BOATER LIABILITY LIMITS *
MEDICAL PAYMENTS
PERSONAL EFFECTS
BAHAMAS COVERAGE REQUESTED *
HOW DID YOU HEAR ABOUT US? HOW MUCH ARE YOU CURRENTLY PAYING? WHO IS YOUR CURRENT INSURANCE CARRIER (IF APPLICABLE)
ADDITIONAL COMMENTS / COVERAGE REQUESTS / QUESTIONS
PLEASE UPLOAD A COPY OF YOUR CURRENT POLICY OR SURVEY OF WATERCRAFT IF APPLICABLE OR EMAIL IT TO TAYLOR@STACKSBROKERAGE.COM

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YOUR PREMIER AGENCY FOR MARINE INSURANCE