SCL Insurance Agency., Inc.

* 1650 Sycamore Avenue, Suite #3, Bohemia, NY 11716 *

* Phone: 631-738-1110 * Fax: 631-738-0312 *


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Watercraft Quote Request


Basic Address Information     (Required fields are marked with *)
*  Name
    Address
*  City *  State Zip:

Please supply either a Daytime or Evening Phone Number " best time to call.
    Day Time Number:
    Evening Number:
*  Best Time To Call
    E-mail:


Request Watercraft Insurance
Marital Status:
*  Current insurance carrier?     How
    Long?
 yrs
Policy Expires?
Date of Birth Drivers Lic# ST#

    Number of
    years experience
    Member of any
    boating association

Purchase price: Loss Payee

Loss Payee(if applicable)
Name:
Address:
City: State: Zip:

Balance Due:

Has insurance ever been declined:
If Yes, explain:

List and detail any losses or claims

Watercraft Information
Year: Length:
Model: Builder:
Hull Identification #: Name of Boat:

Hull Type

Hull Material
If other,

Engine

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 Radar Halon
GPS
Depth Finder VHF

Other:

Navigation
Chesapeake Bay Trib. Inland Water Specify Waters
Atlantic Coast between and
Vessel will be laid up Where:

Vessel in excess of 24' ONLY Ever transported overland If yes, how many miles?

Chartered   Ever used for water skiing?

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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