Please complete this form to receive a premium quotation for Recreational Diving and Excursion Charters. Be as complete as possible so that we may provide you with a premium quotation with no obligation. An application may be needed later.

Your name, e-mail, and phone number, highlighted in RED, are the minimum requirements for the form to properly transfer to our e-mail box.

Name of Operation
Business E-mail Address
Mailing Address
Street Address (if different from Mailing)
City, State and Zip
Contact Person
Position of Contact Person
Name of Principal
Phone No.
Fax No.
Experience in Vessel Operation in Years
VESSEL DESCRIPTION
Vessel Name
Vessel Manufacturer
Power or Sail	Power	Sail
Year Built
Length
Beam
Draft
Hull Material
Certified Number of Passengers
Average Number of Passagers
Hull Serial Number
Number of Engines
HP per Engine
Total HP
Engine Manufacturer
Engine Model
Fuel
County Registered
Registration Number
USCG Number
OPERATION DETAILS
Operation	Dive Snorkel Fishing	Sightseeing Dinner
Other kind of Operation
Average Length of Voyage	Half Day Full Day	Week
Other Length of Voyage
Kind of Operation	Passenger Vessel Time Charter	Voyage Charter 6 Pak Operation
Navigation
Homeport
Layup Period From
Layup Period To
Skippered By	Owner/Operator	Paid Captain
Number of Crew (Excluding Skipper)
Amount of Crew Liability	None 100,000 300,000	500,000 1,000,000
Current Insurer
Premium
Expiration Date
LIMITS REQUESTED
Hull & Machinery	$
Equipment	$
Tender & Motor	$
Personal Effects	$
Liability	$
Medical Payments	$
Other
Amount of Other	$
Food & Drink	Yes	No
Loss Payee	Yes	No
LOSS/CLAIMS HISTORY If none, check here.
Date of Loss #1
Nature of Claim #1
Claim Amount #1
Amount Paid #1
Reserve #1
Open/Close #1
Date of Loss #2
Nature of Claim #2
Claim Amount #2
Amount Paid #2
Reserve #2
Open/Close #2
Date of Loss #3
Nature of Claim #3
Claim Amount #3
Amount Paid #3
Reserve #3
Open/Close #3
Date of Loss #4
Nature of Claim #4
Claim Amount #4
Amount Paid #4
Reserve #4
Open/Close #4
Date of Loss #5
Nature of Claim #5
Claim Amount #5
Amount Paid #5
Reserve #5
Open/Close #5

Note: Copy of current condition & value survey and USCG certificate required.

Please enter any additional information or comments.

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