Marine Liability Insurance Inquiry Form Marinas, Yacht Clubs, Boat Dealers, Ship Repair Yards,
Stevedores & Terminals, etc.
Please complete this form to receive a premium quotation for Marinas,
Yacht Clubs, Ship Repair Yards and Stevedores & Terminals, etc. 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.
Business Name
Business E-mail Address
Mailing Address
Street Address (if different from Mailing)
City, State and Zip
Phone No.
Fax No.
Year Est:
Person Responsible
for Insurance Coverage
Nature of Business (Check all that apply)
Boat Dealer Manufacturer Repair Facility
Yacht Club Marina Operator Resort
Other (Please describe)
Do you have more than one location?
Yes
No
What is your annual Gross Receipts?
0 - 300,000 300,000 - 700,000 700,000 - 1,000,000
1,000,000 - 2,500,000 Over 2,500,000
Have you had any losses/claims in the past five years?
Yes
No
If yes, describe
Who is your current insurer?
Expiration date of coverage:
Current Premium:
Do you own or lease the property?
Own
Lease
If you own the property, what is the value of all real property?
Under 100,000 100,000 - 500,000
500,000 - 1,000,000 Over - 1,000,000
Please check off the coverages you now have or think you might need:
Please enter any additional information or comments.
Thank you for providing us with your coverage requirements. We will review
this information and respond to you promptly. If you have any questions or
comments and want to speak with us, please see our contact information
below.
