****BINDING RESTRICTIONS CURRENTLY IN PLACE FOR VESSELS IN DADE & MONROE COUNTIES*****
YOUR PREMIER AGENCY FOR MARINE INSURANCE --- WATERCRAFT, CENTER CONSOLES, MOTOR YACHTS & SPORTFISH BOTH PRIVATE AND COMMERCIAL RISKS OFFICE@STACKSBROKERAGE.COM // 754-212-4459
Name or LLC
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / 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?
YES
NO
Other
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
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?
*
YES
NO
Number of Engines
*
1
2
3
4
5
Make of Engines
*
Horsepower of Each Engine
*
Model Year of engines
*
Model of Engines
Type of Engine (if other, please specify below)
*
OUTBOARD
INBOARD/OUTBOARD
INBOARD
AIR PROPS
PODS
JET DRIVE)
OTHER
Other Type of Engine
Engine Serial Numbers (IF MULTIPLE, PLEASE PUT SLASH "/" BETWEEN)
Fuel Type
*
GASOLINE
DIESEL
ELECTRIC
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
Other
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 5 years on insurance?
*
YES
NO
How will Watercraft be used
*
PRIVATE
PRIVATE WITH LIGHT CHARTER
FULL TIME CHARTER
CHARTER (6PACK)
LIVE-ABOARD
Other
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
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
*
RACK STORAGE
LIFT
SLIP/DOCK
ON TRAILER INSIDE
ON TRAILER OUTSIDE
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
*
$100,000
$300,000
$500,000
$1,000,000
MEDICAL PAYMENTS
$1,000
$5,000
$10,000
$25,000
$50,000
PERSONAL EFFECTS
$1,000
$2,500
$5,000
$10,000
$25,000
$50,000
BAHAMAS COVERAGE REQUESTED
*
YES PLEASE
NO THANKS
BEST TIME FOR US TO REACH YOU
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
Are you interested in an auto, home, business or jewelry insurance quote? Bundling your boat with other lines could save you $$
*
Yes
No
Which Agent assisted you?
Taylor
Kami
Reed
Austin
Halen
Signature
AGENCY NAME (if applicable)
SMS Opt-In
Yes! Stacks Brokerage may text me throughout the insurance quoting, servicing, claims, and renewal processes
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