Online Quote Sheet
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(*Required Information)
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| Applicant Information |
| First Name: * |
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| Last Name: * |
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| Address: * |
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| City: * |
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| State: * |
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| Zip Code: * |
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| Phone: * |
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| Email: * |
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| Date of Birth: * |
mm/dd/yy
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| SSN: |
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| Occupation: |
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| Drivers License #: |
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| License State: |
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| CGAUX Member #: * |
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| Co-Applicant Information |
| First Name: |
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| Last Name: |
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| Date of Birth: |
mm/dd/yy
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| Boat Information |
| Manufacturer: * |
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| Model: |
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| Year: * |
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| Hull Type: * |
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| Hull Serial #: |
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| Hull Material: * |
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| Drive Type: * |
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| Length: * |
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| Speed: * |
mph
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| Engine Make: * |
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| # of Engines: * |
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| Total Horsepower: * |
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| Fuel Type: * |
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| Current Value: * |
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| Date of Last Survey: |
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| Surveyed Market Value: |
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| Navigation Limits: * |
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Safety Equipment:
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Depth Finder |
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VHF Radio |
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High Water Alarm |
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Radar |
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EPIRB |
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CO Detector |
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GPS |
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Auto Fire Extinguisher in Engine Space |
| Address where boat is kept in season: * |
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| Facility Type: * |
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| Address where boat is kept out of season: |
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| Facility Type: |
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| Lay Up Period From: |
mm/dd
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| To: |
mm/dd
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Trailer (If Applicable)
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| Make: |
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Year:
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Operator Information
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| Coxswain Qualification: * |
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| Boat Crew: * |
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| Qualified Facility? * |
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| % of Total Use Under Orders: * |
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| # of Years of Boating Experience: * |
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| # of Motor Vehicle Violations in last 3 yrs (date, details): * |
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| All Marine Losses (date, amount, details): * |
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| Secondary Operator Name: |
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| Date of Birth: |
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| # of Years of Boating Experience: |
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| # of Motor Vehicle Violations in last 3 yrs (date, details): |
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| All Marine Losses (date, amount, details): |
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| Current Carrier: * |
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Coverage & Limits
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| Deductible: |
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| Watercraft Liability: * |
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| Medical Payments: |
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| Personal Effects: |
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| Towing: |
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| Trailer: |
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| Fishing Equipment: |
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| Boat Lift: |
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| Additional Information |
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