Please complete the following in as much detail as possible to assure we can provide you with the most competitive rate, or phone us at 1-800-990-9283 for an immediate charter insurance quote.
*Email address required.
Please fill out the form over the Name and Date Prompts text for proper form transmission.

Full Name:
Address:
City:
State/Province:
Zip code/Postal zone:
Country:
Drivers License State and Number:     --- Select --- AL AK AP AR AZ CA CO CT DC DE FL GU GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VI VT WA WI WV WY
Telephone:
Fax:
*E-mail:
Occupation:
Date Of Birth:
Years of boating experience:
Size and builder of previous boats owned:
Are course/member certificates available?	Power Squadron USCG Auxillary USCG Captain License None
Motor vehicle driving record past 5 years:
Are there other operators of this vessel?	Yes No

CHARTER BOAT INFORMATION
NAME OF VESSEL:
YEAR:
MANUFACTURER/BUILDER:	--- Select --- Albin Alden Avanti Azimut Baha Bayliner Benetti Benneteau Bertram Blackfin Black Watch Blue Water Boston Whaler Bristol Broward Buddy Davis Burger Burnside C+C Cabo Rico Caine Cal Californian Cape Dory Carolina Skiff Carver Catalina Chaparral Choey Lee Chris Craft Christensen Cobia Codecasa Columbia Contender Contest Cooper Cruisers Inc. CSY Davis DeFever Donzi Doral Dufour Dusky East Bay Eastbay Egg Harbor Eliminator Endeavor Erickson Fairline Feadship Ferretti Formula Fountaine Pajot Fountain Four Winns Freedom Gemini Grady White Grand Banks Gulfstar Hallberg-Rassy Hans Christian Hatteras Harris Henriques Hinckley HiStar Hunter Hutchins Hydra-Sport Infinity Intrepid Irwin Island Gypsy Island Packet Islander J Boat Jenneau Jefferson Jersey Krogen Lagoon Little Harbor Luhrs Main Ship Maiora Mako Mares Marine Trader Magnum Maxum Monk Monterey Moody Morgan Nauticat Newport Nordic Northstar Nova Ocean Alexander Ocean Yacht Offshore Pacemaker Pacific Seacraft Pacifica Palmer Johnson Passport Yachts PDQ Pearson Penn Yan Performance Cat Phoenix Post Proline President Yachts Prout Pursuit Queenship Rampage Ranger Real Ships Regal Regulator Rinker Robalo Robinson S2Yachts Sabre Sea Ray Schock Silverton Sonic Southern Cross Soverel Stamas Stryker Sunseeker Swan Ta Chiao (CT) Ta Shing Tanaya Tartan Tiara Tollycraft Topaz Trinity Trojan Uniflite Viking Valiant Wahoo Wellcraft Westbay Westerly Westport Westship Worldcat
If your builder is not listed above please add your builder here:
MODEL:
TYPE OF VESSEL:	--- Select --- Cruiser Houseboat Motor Yacht Performance Runabout Sail Yacht Sportfisher Trawler Other
LENGTH:
PURCHASE PRICE OF VESSEL:
DATE OF PURCHASE:
FLAG:	US Foreign
MAXIMUM SPEED:
HULL TYPE:	--- Select --- Catamaran Monohull Other
HULL MATERIAL:	--- Select --- Fiberglass Aluminum Steel Wood Other
ENGINES:	NUMBER: --- Select --- 1 2 3 4 FUEL TYPE: --- Select --- Gas Diesel HORSEPOWER EACH......... MANUFACTURER.............. --- Select --- Caterpillar Crusader Cummins Detroit Evinrude GM Honda John Deere Lehman Mercruiser MTU Perkins Volvo Yamaha Yanmar Other DRIVE TYPE... --- Select --- Inboard Outboard In/outboard Other
AUTO FIRE EXTINGUISHERS:	--- Select --- Yes No

VESSEL USAGE AND LOCATION
PRIVATE PLEASURE PART TIME CHARTER FULL TIME CHARTER IF CHARTER- MAX. NUMBER PAYING PASSENGERS/GUESTS: WHERE IS THE VESSEL MOORED?
NAVIGATION LIMITS
Waters navigated next twelve months:
Is vessel ever laid-up?	Yes No
What months is she out of commission?	--- Select --- Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec to --- Select --- Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
If laid up, is vessel stored:	--- Select --- Ashore In Water
Will anyone be living aboard the vessel during the policy period?	Yes No

PRESENT AND PAST INSURANCE INFORMATION
PRESENT INSURANCE CO.:
EXPIRATION DATE OF POLICY:
CURRENT PREMIUM:
OWNED BOATS SINCE:
Have you had any yacht insurance claims in the past 10 years?	Yes No

Please enter the year, amount, and a brief outline of the loss/claim.

COVERAGES REQUESTED
Hull and equipment value:$ Tender/Dinghy $ Year Trailer............ $ Year Survey Available: --- Select --- No Yes Survey Date Survey conducted: --- Select --- Afloat Ashore
LIABILITY COVERAGE  (Protection and indemnity) --- Select --- $100,000 $300,000 $500,000 $1,000,000 Other
Paid Crew --- Select --- Yes No Number of Paid Crew:
Comments

Charter Boats Insurance
by W.R. Hodgens Marine Insurance, Inc.
1425 South Andrews Ave Suite 250	Fort Lauderdale, FL 33316
Ph: 954-523-6867	Fax: 954-523-6488
Toll Free USA:  800-990-WAVE (9283)

©W.R. Hodgens Marine Insurance, Inc. Terms & Conditions

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