QUOTE REQUEST FORM

Please complete and submit the form below so that we can begin our inquiries into finding the best options for you among the many insurance companies we have available. If you would rather complete the form offline, you can download versions of this form in Adobe Acrobat, Microsoft Word and plain text formats.  In any case, please just relax
and tell us all about it.

Applicant Information

The personal information you provide will not be used by Manifest Marine or the insurers it represents except for the purpose of determining the present availability
and cost of the insurance you specify below.  Some insurers we represent check driving, claims and credit histories in order to determine the availability and cost of
their insurance; please mention in the Comments section if you do not wish to consent to this.  The contact information you provide will not be used by us or
others to contact you again at a later time unless you choose to have Manifest Marine arrange such insurance for you. (Privacy Notice)
Name of applicant:
Mailing address: (include the city, state and postal code
of your address, and, if it is outside the
U.S.A., include the country; carriage
returns allowed in this multi-line field)
Telephone number:        E-mail 
Occupation: (if retired please also indicate prior occupation)
Citizenship:     Driver license  (number and issuer)
Date of birth:     Years boating     Years as boatowner 
Largest prior vessel: (describe vessel, years owned and where operated)
Second largest vessel: (describe vessel, years owned and where operated)
Boating courses taken: (please also list any boating licenses held)
Place a check next to any of the following statements that are true:
I have been cited for a boating or motor vehicle violation in the past five years.
I have made an insurance claim against a boat or motor vehicle insurance policy in the past ten years.
I have been denied an insurance policy by an insurance company for boat or motor vehicle insurance.
I have had a boating or motor vehicle license suspended or revoked.
I have been convicted of a felony.
Someone will operate the vessel on a regular basis without me aboard.
A captain or crewman will be hired to operate or assist in the operation of the vessel.
The vessel will be operated singlehandedly in cases other than an emergency.

If any statement was checked, please provide details of the relevant circumstances in the Comments section below.

Vessel Information

Owners (if other than applicant named above)
Boat name     Builder  
Model     Style  
Year     Length       Construction  
Place built     Place registered  
Propulsion             
                   

 

Equipment

 

 

                   
                        
              

Spars      Rigging age (for sailboats, specify material of the spars and age of the standing rigging)
Damage (please describe any existing damage or other faults of the vessel)
Survey (indicate date of latest professional survey and whether or not the vessel was ashore for this; if available, please attach a copy of the report)

Usage Information

Type of use                    
        
Time of use
      
   
Area of use     
                             
                    
Mooring
  
         

Coverage Information

Present insurer of vessel     Expiration date of policy  
Purchase cost of vessel     Date of purchase  
Estimated current value (if higher than purchase cost, describe why in Comments section below)
Desired insurance amount (if other than current value, describe why in Comments section below)
Deductible                          (percentage of insurance amount)
Value of dinghy & motor (portion of current value attributable to dinghy & its motor)
Value of trailer (portion of current value attributable to boat trailer)
Liability insurance $300,000              

Comments

Please use the space below to expound upon any of the information provided above or to advise us of any peculiar
circumstances of which we should know  If any use other than recreational was indicated above, please provide below
details of the planned use.  Please also use the space below to specify any supplemental coverages in which you are
interested.

 

Please let us know how you learned about Manifest Marine:

Before submitting, enter the validation code 3757 here:                                

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Last edited August 24, 2020 13:07
© Manifest Marine