Manifest Marine Quote Request

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

Type: Gasoline Diesel Other Year/Manufacturer:
Single Twin Triple HP each: Maximum MPH:

Equipment

Automatic fire extinguisher      Fume detector      Theft alarm      High water alarm
RADAR      VHF radio      Depthsounder      GPS      AIS
Dinghy with motor      Dinghy w/o motor      Liferaft      Trailer

Particularly if the vessel will be traveling internationally, please describe any additional safety, navigation or other equipment aboard or other preparations you have made to enhance the seaworthiness of the vessel and the safety of its crew. (carriage returns allowed in this multi-line field)

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	Recreational Liveaboard Racing Trailering Waterskiing Bareboat charter Crewed charter Commercial use other than charter
Time of use	Year-round use Kept in port From: Until: Stored ashore From: Until:
Area of use	Coastal waters Between: And: Nontidal waters of U.S. Bahamas Cuba Caribbean Mexico Canada Great Lakes Chesapeake Bay San Francisco Bay Puget Sound Other:
Mooring	Regularly cruising Year-round At: Seasonal Summer at: Winter at:

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, itemize additional dollars invested in space below)
Desired insurance amount	(if other than current value, describe why in space below)
Deductible	1% 2% 3% 4% 5% 10% (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 $500,000 $1,000,000 Other: