ROBINSON-MAURER-WELTS

Insurance Brokers & Consultants ~ Seattle
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Boat / Yacht Insurance Quote
To obtain a quote for your boat or yacht, please complete the form below. We will shop your policy with the best insurance providers and will contact you within one business day to review your comparative quotes.

PLEASE READ BEFORE SUBMITTING APPLICATION:
This application will be incorporated in its entirety into any relevant policy of insurance where Insurers have relied upon the information contained herein. Any misrepresentations or concealment in this application for insurance will render insurance coverage null and void from inception.

Please therefore check to make sure that all questions have been fully answered and that all facts material to your insurance have been disclosed, if necessary by a supplement to the application.  A consumer report containing personal, credit, factual or investigative information about the applicant may be sought in connection with this application for insurance or any renewal, extension or variation thereof. 

Signing this form does not bind the Applicant to purchase the insurance or the Insurer to accept the risk, but it is agreed that this form shall be the basis of the contract should a policy be issued.
 
NOTE: INSURANCE IS NOT IN EFFECT UNTIL COVERAGE IS BOUND. Binders expire 15 days from the effective date.

 

Requested Effective Date
Named Insured
Registered Owner(s) if different
Home Phone
Work Phone
Home Fax
Work Fax
Email Address
Preferred method of contact
Street Address
City, State, Zip
County
Date of Birth
Occupation
Employer
Current carrier for Homeowners and/or Auto Insurance?
Do you have an Umbrella Insurance policy?
Years of Boat Ownership
Years as Operator/Crew
Expiration of Current Policy
Previous Insurer (this or prior)
Previous Insurer Policy #
Size and type of previous boats
Member of cruising club
Boating education courses
Boating losses in the past 3 years (claimed or otherwise). Give full details including date, description and amount paid
Hull and Machinery - Year Make and Model
Hull and Machinery - Length, Beam and Horse Power
Hull and Machinery - Registration #
Hull and Machinery - Hull ID #
Hull and Machinery - Replacement Cost
Hull and Machinery - Market Value
Hull and Machinery - Purchase Price
Hull and Machinery - Date Purchased
Outboard / Auxiliary Motor - Year Make and Model
Outboard / Auxiliary Motor - Serial #
Outboard / Auxiliary Motor - Value
Dinghy - Year Make and Model
Dinghy - Serial #
Dinghy - Value
Dinghy Motor - Year Make and Model
Dinghy Motor - Serial #
Dinghy Motor - Value
Total Hull and Machinery - Value
Trailer - Year Make and Model
Trailer - Serial #
Trailer - Value
Liability Limit
Loss Payee/Lienholder Name
Loss Payee/Lienholder Loan #
Loss Payee/Lienholder Street Address
Loss Payee/Lienholder City State Zip
Operator 1 (Name, Date of Birth, Drivers License #)
Operator 2 (Name, Date of Birth, Drivers License #)
Operator 3 (Name, Date of Birth, Drivers License #)
Operator 4 (Name, Date of Birth, Drivers License #)
If moored at a marina, Marina Name
Marina Street Address
Marina City State Zip
Ashore / Afloat
Is yacht transported overland?
If so, how far?
How Often?
Type of Vessel
Construction
Sleeping Quarters
Galley
Head
Radar
Depth Finder
S/S Radio
Loran
Compass
Vapor Detection
Propane
GPS
Autopilot
Built In Co2 Halon
Type of Fuel
No. Fire Extinguishers
Maximum Speed
Number of Engines
Engine Manufacturer
Motor
Live Aboard?
Any chartered use?
Navigation limits requested
Have you ever had any insurance refused or cancelled (If yes, explain)