SCL Insurance Agency., Inc.
* 1650 Sycamore Avenue, Suite #3, Bohemia, NY 11716 *
* Phone: 631-738-1110 * Fax: 631-738-0312 *
Watercraft Quote Request
Basic Address Information
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*
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Please supply either a Daytime or Evening Phone Number " best time to call.
Day Time Number:
Evening Number:
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Best Time To Call
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Morning
Afternoon
Evening
E-mail:
Request Watercraft Insurance
Marital Status:
Single
Married
Divorced
Separated
Widowed
*
Current insurance carrier?
How
Long?
yrs
Policy Expires?
Date of Birth
Drivers Lic#
ST#
Number of
years experience
Member of any
boating association
Yes
No
Purchase price:
Loss Payee
Yes
No
Loss Payee
(if applicable)
Name:
Address:
City:
State:
Zip:
Balance Due:
Has insurance ever been declined:
Yes
No
If Yes, explain:
List and detail any losses or claims
Watercraft Information
Year:
Length:
Model:
Builder:
Hull Identification #:
Name of Boat:
Hull Type
Cruiser
Trawler
Sail
Houseboat
Runabout
Personal Watercraft
Hull Material
Fiber Glass
Wood
Other
If other,
Engine
Gas
Diesel
Inboard
Outdrive/I/O
Outboard
Jet Drive
Year:
Manufacturer:
How many:
HP each:
Max Speed (MPH):
Engine(s) S#:
Trailer
Year:
Length:
MFG:
S#:
Tender
Year:
Length:
MFG:
S#:
Tender's Motor
Year:
Length:
MFG:
S#:
Equipment
Loran
Yes
No
Radar
Yes
No
Halon
Yes
No
GPS
Yes
No
Depth Finder
Yes
No
VHF
Yes
No
Other:
Navigation
Chesapeake Bay Trib.
Yes
No
Inland Water
Yes
No
Specify Waters
Atlantic Coast between
and
Vessel will be laid up
Ashore
Afloat
Where:
Vessel in excess of 24' ONLY Ever transported overland
Yes
No
If yes, how many miles?
Chartered
Yes
No
Ever used for water skiing?
Yes
No
Coverage
Effective Period From
to
VALUES
DEDUCTIBLE
PREMIUM
Hull and Machinery
Outboard Motor
Equipment
Tender and its Motor
Trailer
Liability
Medical Payments
Overland Transp. (miles)
Uninsured Boaters
Personal Effects
Assistance/Towing
Total Premium
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